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HomeMy WebLinkAboutResolutions - 1997.02.13 - 25028MISCELLANEOUS RESOLUTION 197018 BY: Public Services Committee, Shelley Taub, Chairperson RE: Community Mental Health FY 96-97 Full Management Contract with Michigan Department of Community Health TO THE OAKLAND COUNTY BOARD OF COMMISSIONERS Chairperson, Ladies and Gentlemen: WHEREAS the full management contract between the Michigan Department of Community Health and Oakland County Community Mental Health as the County agent specifies the terms and conditions for funding and service delivery of the Oakland County Community Mental Health Board Programs; and WHEREAS the 1995/96 full management contract has been extended for a 90 day period that commenced on 10/1/96 and expired on 12/31/96, but was extended for another 60 day period that will expire on 3/1/97; and WHEREAS Oakland County Community Mental Health Staff in cooperation with Oakland County Corporation Counsel, have developed recommended modifications to the Department's standard language to suit the needs of Oakland County and incorporate language that includes the ability to assign the contract to a CMH Authority once established. The modifications also include clarifying statements to eliminate potential County shared risk related to the Medicaid Managed Care targets; and WHEREAS the Oakland County Community Mental Health Board approved this contract on January 21, 1997. NOW THEREFORE BE IT RESOLVED that the Oakland County Board of Commissioners approves the attached text "Michigan Department of Community Health/Oakland County Community Mental Health Services Board Contract for Full Management" for FY 1996-97 and all attachments. BE IT FURTHER RESOLVED that the Biennial Budget is amended as follows: Community Mental Health Fund (22297) FY 1996/97 FY 1997/98 Revenues 550-01-00-2589 State Matching Payments $1,816,180 $1,816,180 550-01-00-8101 County Match 116,779 116,779 557-05-10-2500 Medicaid Waiver - Federal Share 46.650 46.650 Subtotal $1.979.609 $1.979,609 Expenditures 550-05-00-3282 Contingency $1,823,118 $1,823,118 557-05-10-3042 Child Model Waiver - Client Services 84,557 84,557 559-53-10-3042 MORC - DD SIP's (Section 307 Transfer Funding) 71.934 71.934 Subtotal $1,979,609 $1,979,609 TOTAL Chairperson, on behalf of the Public Services Committee, I move the adoption of the foregoing resolution. PUBLIC SEI:VICESSCOMITTEE MICHIGAN DEPARTMENT OF COMMUNITY HEALTH/ OAKLAND COUNTY COMMUNITY MENTAL HEALTH SERVICES BOARD FULL MANAGEMENT CONTRACT - FY '96 -97 PART I A. General Provisions. 1. The Michigan Department of Community Health, an agency of the State of Michigan ("State"), herein referred to as the "Department," and the County of Oakland, .a Michigan Constitutional Corporation, herein referred to as the "County," by and through its statutory agent the Oakland County Community Mental Health Services Board, herein referred to as the "Board," agree to the provisions of this Contract for the purpose of ensuring the provision of services to identified populations according to standards and policies as specified in this Contract. Notwithstanding any provisions in this Contract, the Department shall retain its Constitutional and statutory responsibility for providing Mental Health services for county residents, with the Board acting under contract with the State. Nothing in this Contract shall require the County of Oakland (hereinafter the "County") to commit funds in excess of the local match requirements established in Act 258 of the Public Acts of 1974, as amended (hereinafter the "Michigan Mental Health Code"), or to authorize or allocate any County funds for any Board purpose beyond such amount. 2. The Department enters into this Contract under the authority granted by Section 116 (e) and (j) and Section 228 of the Michigan Mental Health Code, as amended, and the provisions of that Code, all rules promulgated. and adopted under that Code, and applicable State and federal laws shall govern the expenditure of funds and provision of services. The Board enters into this Contract under the authority granted in Section 226(g) and 228 of the Michigan Mental Health Code and by Oakland County Board of Commissioners Miscellaneous Resolution 93092, or pertinent subsequent resolutions authorizing full management status. 3. This Contract shall not be construed to establish any employer-employee, or principal-agency relationship between employees of the County or the Board and the Department, nor between any of the Board's subcontractors or subcontractors' employees and the Department. FULL MANAGEMENT CONTRACT FY '96-97 - Page 2 4. The Board shall have the freedom to arrange for the provision of mental health services as it deems necessary and appropriate, in accordance with the rules and policies of the County and the Oakland County Board of Commissioners. The Board may subcontract for the provision of any of the services specified in this Master Contract. Terms and conditions of its subcontracts shall be within the exclusive discretion of the Board and not subject to the review of the Department. The Board shall ensure that • all such subcontracts are consistent with the provisions of this Master Contract, which shall prevail in the event of conflict. Subcontracts must ensure that neither the Department nor the County is a party to any employer/employee relationship with a contractee of the Board. 5. This Contract shall be in effect from October 1, 1996 through September 30, 1997, unless extended as provided in Part I, A.(15), or amended or terminated according to the provisions for amendment or termination as provided for herein. The Department shall respond in writing to the submission of a contract covering a new fiscal year within thirty (30) days of submission of the document, signed by the Board, to the Department's area manager. Such response shall include either approval of the contract or identification of specific reasons for failure to approve. If such response is not provided within 30 days, the new contract shall be deemed approved and its conditions shall prevail. 6. Amendments may be made only by written agreement of the Department, and the Board acting under the authority of Oakland County Board of Commissioners resolution authorizing such an amendment. All requests s for amendments must be submitted by September 30 of the Contract year. However, if the Board's budget authorization is amended by the Department at any time after August 1 of the Contract year, an extension of the September 30th deadline shall be granted by the Department, sufficient to allow the Board to approve and submit a revised Summary of Projected Funding accordingly. Amendments may be made at any time during the life of the Contract. Such amendments may alter any of the terms of the Contract including the General Provisions, Board Assurances, Department Assurances, and Attachments as well as the material financial considerations included in Part IV of the Contract. 7. The Board is required to review and resubmit to the Department the Part V - Summary of Projected Funding on April 30 and June 30 of each fiscal year. These submissions are intended to reflect adjustments to the ' projected expenses and revenues of the Board under the Contract based FULL MANAGEMENT CONTRACT FY '96-97 - Page 3 on program revisions approved by the Board and actual utilization of facilities, and may amend the material financial considerations contained in the Contract. The submission of June 30 shall include a projection of total CMH lapse. Should circumstances substantially alter the June 30th expenditure projection, the Board will submit an amendment to reflect this. The final amendment will constitute the Board's final projection of lapse. Total Board expenditures of Department funds are limited by the amount of the DCH MAXIMUM FUNDING authorization contained in the final SUMMARY OF PROJECTED FUNDING (Part V, Section IV, 2 of this Contract). Should total actual expenditures deviate from the projection contained in the final amendment by more than twenty percent (20%), the Board will develop, with the assistance of the Department, a plan to remediate the Board's projection methods. Should this deviation continue in the next year, cash flow advances to the Board shall be adjusted to actual expenditures. The Department will notify the Board thirty (30) days in advance of any such change in the Board's cash advance. 8. In the event that either the Department or the Board claims the other is not in compliance with a provision of this Contract, a written notification may be initiated by the concerned party. Such notification shall include a statement of specific areas of alleged non-compliance. A written response to such notification shall be provided by certified mail within thirty (30) calendar days of receipt of the notification. The response shall either (a) present facts which refute the allegation of non-compliance, or (b) present a proposal for remediation which may include amendment to the Contract. Should the concerned party find the response to be unsatisfactory, a request for a review involving the Department Director and the Board Director will be held. Such review shall be scheduled' within thirty (30) days of receipt of the request. The results of this review shall be provided in writing to the parties within fifteen (15) days of the completion thereof. 9. This Contract may be terminated by either the Department or the County/Board by giving one hundred eighty (180) days' notice in writing to the other party by certified mail. Such termination shall not relieve either party of any obligations incurred prior to the effective date of such termination. It is mutually agreed that if total State funding for all programs and populations for the Board, without regard to inter-county transfers of funding for residential services, drops below either (a) 95% of the previous ' year's full-year cost funding, or (b) the final State authorized funding level FULL MANAGEMENT CONTRACT FY '96-97 - Page 4 97FMK A3.VVPD for the year of inception of this Contract (Fiscal Year 1992-93), as adjusted for inflation based on the national Consumer Price Index, whichever is greater, then this shall cause the Contract to cease within one hundred twenty (120) days or a period of time mutually agreed upon, unless otherwise agreed by the Oakland County Board of Commissioners. 10. All liability to third parties, loss, or damage as a result of claims, demands, costs, or judgments arising out of activities, such as direct service delivery, to be carried out by the Board in the performance of this Contract shall be the responsibility of the Board, and not the responsibility of the Department, if the liability, loss, or damage is caused by, or arises out of, actions or failure to act on the part of any employee of the Board, any subcontractor, or anyone directly or indirectly employed by the Board, including Board members, officials or agents. Nothing herein shall be construed as a waiver of any governmental immunity that has been provided to the County and/or the Board, their agencies or employees by statute or court decisions. All liability to third parties, loss, or damage as a result of claims, demands, costs, or judgments arising out of activities, such as the provision of policy and procedural direction, to be carried out by the Department in the performance of this Contract shall be the responsibility of the Department, and not the responsibility of the County or the Board, if the liability, loss, or damage is caused by, or arises out of, actions or failure to act on the part of any Department employee or agent. Nothing herein shall be construed as a waiver of any governmental immunity by the State, its agencies or employees as provided by statute or court decisions. In the event that liability to third parties, loss, or damage arises as a result of activities conducted jointly by the Board and the Department in fulfillment of their responsibilities under this Contract, such liability, loss, or damage shall be borne by the Board and the Department in relation to each party's responsibilities under these joint activities. Nothing herein shall be construed as a waiver of any governmental immunity by the County, the Board, the State, the Department, or their employees respectively, as provided by statute or court decisions. 11. All costs, including reasonable attorney fees, which the County and/or the Board may incur in the event that the courts of this state hold that a co-employer status exists with reference to persons employed in non-inpatient residential facilities whose contracts have been transferred from a Department hospital/center to the Board, shall be the responsibility ' of the Department and not the responsibility of the County or the Board, FULL MANAGEMENT CONTRACT FY '96-97 - Page 5 provided that said costs are attributable solely to that period of time prior to the transfer of contracts for such residential facilities from the State of Michigan to the Board. 12. In the event that circumstances occur which are not reasonably foreseeable, or are beyond the Board's or Department's control, which reduce or otherwise interfere with the Board's or Department's ability to provide or maintain services, or operational procedures specified in this Contract, the affected party to the Contract shall immediately notify the other party and shall negotiate a revision of the Summary of Projected Funding reflective of the reduction, which shall become an amendment to this Contract. Examples of such occurrences include, but are not limited to, default of subcontracts, acts of God, damage to facilities, employee strikes, and ruling(s), order(s) and/or opinion(s) of a State or Federal Court. 13. Department policies to be implemented by the Board during the life of the Contract shall be limited to those policies enumerated in this Contract, including its Attachments. This Contract shall be governed by applicable Federal and State statutes. 14. The Board and the Department agree that performance objectives will be developed and are as shown in Attachment A to this Contract. These objectives will be initiated with publication of public mental health system priorities in the Department's annual planning guidelines which shall specify objectives for the State mental health system. The Board, or the Department, may initiate development of one or more objectives for the Board in addition to those specified for the entire State. Details of such objectives will be finalized by mutual consent of the parties. Performance objectives will contain: • A statement of measurable outcome. Measurement of objectives shall be guided by the requirements of the Mission Based Performance Indicator System where possible. *.A statement of activities intended to support attainment of that outcome. These activities may involve Board staff, Department staff or both. Interim benchmarks and time frames will be specified. • A plan for reporting interim progress in attaining the objective, as well as for reporting progress at the end of the Contract period. FULL MANAGEMENT CONTRACT FY '96-97 - Page 6 97FMK A3.VVPD The final report of progress shall be submitted not later than December 31 of each year. An interim report shall be submitted no later than September 1 of each year, and shall be used in development of the following year's objectives for the Board. The Department shall make available to CMH Boards a summary describing attainment in the previous year of Statewide objectives, no later than March 1 of each year. This summary shall be based on reports submitted on December 31. Failure to meet one or more performance objectives shall not result in an allegation of non-compliance with the Contract, when good- faith efforts to pursue the activities agreed-upon can be demonstrated by the Board. 15. In the event that a new Contract is not signed by the expiration date of this Contract, to-wit: September 30, 1997, the terms, conditions and funding levels contained herein shall remain in effect and be considered renewed for any subsequent Fiscal Year, subject to legislative appropriation, for ninety (90) days following issuance of the Board's base continuation allocation and appropriated economic increases applicable to the new fiscal year. By mutual written consent, this Contract, in whole or in part, may be extended further. The conditions in the Contract governing fiscal year closing and cost settlement of the previous year's Contract shall pertain if the Contract is continued. 16. Inquiries and requests concerning the terms and conditions of this Contract, including requests for amendment, should be directed by the Board to the attention of the Department's Area Manager serving the Board's area, or by the Department's Area Manager to the Board. Performance and expenditure reports should be submitted to the Department of Community Health, Finance Division, with a copy to the Area Manager, and a copy to the Department's Division of Contract Management and Administration, Lansing, Michigan. 17. The Board and Department agree that each will notify the other immediately of pending legal action which may result in the other party being named, or which may result in a judgement which would limit the Board's ability to continue service delivery at the current level. This notification requirement includes actions filed in courts or governmental regulatory agencies. 18. Notwithstanding any provision of this agreement to the contrary, this Contract shall not be construed or interpreted to permit a violation of the • Consent Judgment of July 29, 1991, entered in the matter of Oakland FULL MANAGEMENT CONTRACT FY '96-97 - Page 7 County v State of Michigan Department of Mental Health, et. al., Oakland Circuit Court Case No. 85-305141 CZ, nor shall it constitute a waiver of the provisions of said judgment by Oakland County. Further, it shall not be construed to allow a violation of Const. 1963, art. 9, 29. B. Board Assurances The Board agrees: 1. To ensure the provision of services to populations designated in Parts III and IV of this Contract, consistent with designations contained in the Michigan Mental Health Code and Administrative Rules. The populations to be served shall include: a. Individuals located in the service area of the Board who are not residents of Department inpatient facilities or Department- contracted residential settings; and b. Individuals located in Department inpatient facilities or Department- contracted residential settings for whom the Board is responsible under the Michigan Mental Health Code, section 306. c. Except as otherwise provided for in the two previous paragraphs, individuals serviced or cared for through the Department placement agency known as the Macomb-Oakland Regional Center ("M.O.R.C."), for whom the Board (County) is financially liable for the cost of care under P.A. 258, Sec. 306, and discharged to the . Board following the closure of M.O.R.C. on September 30, 1996. 2. To comply with the operational procedures specified in Part VI of this Contract. 3. To immediately notify the Department of modifications in provision of services and compliance with operational procedures under the following conditions: FULL MANAGEMENT CONTRACT FY '96-97 - Page 8 a. Action by the Oakland County Board of Commissioners which reduces the Board's funding for, or authority to provide, specified services. b. Action by the Oakland County Board of Commissioners which reduces the Board's funding level below that required to maintain specified services in the Board's service area. c. Action by Federal or local funding sources which removes funding or reduces the Board's funding levels below that required to maintain specified services in the Board's service area. In the event of any or all of the conditions specified in "a" through "c" occurring, the Board shall submit a revision of its Summary of Projected Funding reflective of the reduction, which shall become an amendment to this Contract. Such amendments shall be received by the Department as provided in item A(6), above. Failure by the Department to approve or deny the request within 30 days shall constitute approval. 4. To permit authorized representatives of the Department, or a properly identified representative of a Michigan Department of Community Health Seeiel-Seirvieee Medicaid Agency Review Office, to make such review of the records of the Board as may be deemed necessary to satisfy audit purposes. 5. To comply with program and fiscal standards identified in Attachment A, which is attached to and made a part of this Contract. The Board may. request a permanent waiver of any provision of Attachment A. 6. To furnish to the Department statistical and other management information according to time frames and reporting formats designated in this Contract. Should additional statistical or management information be requested by the Department, at least forty-five (45) days' notice shall be provided. 7. A preliminary written estimate of anticipated accounts payable to the Department or accounts receivable from the Department shall be submitted within 30 days following the end of the Contract year. The final year-end report shall be submitted within ninety (90) days following the end of the Contract year. The reporting requirements for grant projects shall be specified in the agreement governing the grant, which shall be appended to and become a part of this Contract. FULL MANAGEMENT CONTRACT FY '96-97 - Page 9 8. To ensure the collection of information consistent with the DCH information requirements contained in this Contract and its Attachments. The standard reports included as Attachment B to this Contract shall be submitted on the dates indicated on the report forms; those reports include the Supported Employment report form and reports required for implementation of Managed Care. The Department may specifically request other reports with at least forty-five (45) days' notice. 9. To furnish to the Department information regarding the cost/charge for Medicaid-covered services, for the purpose of analysis and review by the Department pursuant to possible revisions of Medicaid fee screens. 10. The Board recognizes that expansion funding is appropriated by the legislature or granted by the Federal Government for specific purposes and with specific implementation time frames. These purposes and time frames for implementation are contained in letters to the Board authorizing the funding. The Board agrees to report to the Department progress made in implementation of such program developments consistent with expectations outlined in the authorization letter(s). C. Department Assurances The Department agrees: 1. To provide funds to the Board as stipulated in Part V of this Contract. 2. To ensure funding stability, subject to the availability of appropriated and allocated funds, to the Board/County during the life of this Contract. The Department shall immediately notify the Board of modifications in funding commitments in the this Contract under the following conditions: a. Action by the State legislature which removes the Department's funding for, or authority to provide for, specified services. b. Action by the State legislature which reduces the Department's funding level below that required to maintain services on a Statewide basis. c. Action by the Governor pursuant to Const. 1963, art. 5, 320 which removes the Department's funding for specified services, or which reduces the Department's funding level below that required to • maintain services on a Statewide basis. FULL MANAGEMENT CONTRACT FY '96-97 - Page 10 d. A formal directive by the Governor, or Department of Management and Budget on behalf of the Governor, requiring a reduction in expenditures below that incorporated in contracts with CMH Boards. In the event of any of the conditions specified in "a" through "d" occurring, the Department shall submit a proposed revised funding authorization which the Board shall incorporate as an amendment to this Contract. 3. That, in the event of a reduction of funding to the Board, the Board shall decide, subject to the provisions of Part I, Section A, item 9, how the reduction is to be implemented within its programs, within policy established in the Michigan Mental Health Code and Administrative Rules. 4. To permit the Board to redirect funds as clients move to more appropriate treatment settings, with the exceptions of funds identified in Part V of this Contract as Categorical Funding. However, such Categorical Funding shall be automatically rolled over into the Board's base funding after three years, unless contraindicated by legislative appropriation or conditions of original funding. If movement of clients and the funds associated with their care results in cost savings, the Board may utilize funds saved for the purpose of expanding or improving the Board's program. Redirection of funds and cost savings realized as a result of movement of clients to more appropriate treatment settings shall be included in the Board's base program for the purpose of planning for all subsequent years. pregrem-er-pepttletien7 Funds authorized to the Board by the Department for specified purposes, identified as such on their official authorization, and identified as Categorical Funding in Part V, of this Contract shall not be redirected without prior approval of the Department. 5. FULL MANAGEMENT CONTRACT FY '96-97 - Page 11 e3-e-fe3trit7 6. That it will cooperate and assist in the Board's effort to pursue and collect funds from third parties, whenever possible. The Department agrees to supply to the Board at the time of completion, copies of each State hospital/center's ability-to-pay determination on each Oakland County resident admitted to a State facility, and to inform the Board of any claims on the financial assets of consumers and their families and of any appeals by consumers or their families. 7. To ensure that the Department and its hospitals and centers will pursue all possible first- and third-party reimbursements. 8. To provide the Board rates for State-managed services no later than October 1, of each Contract year. Rates shall be issued which include the net rate paid by full management boards and the local share of facility billings. 9. That the protection and investigation of rights of recipients while on inpatient status at Department hospitals and centers shall be the responsibility of the Department of Community Health, Office of Recipient Rights. The Department's Office of Recipient Rights shall share appropriate information on investigations related to the Board residents, including formal complaints and incident reports filed. 10. To conduct an annual review of Medicaid fee screens in relation to the cost of services, and to pursue revisions where warranted. 11. That it may conduct any of the following reviews/audits of the Board during the life of this Contract: a. Financial/compliance audit of the Board. b. Review of the Board's program for the purpose of maintaining Medicaid provider eligibility and/or the eligibility of specific programs for Medicaid reimbursement. FULL MANAGEMENT CONTRACT FY '96-97 - Page 12 c. Review of the Board's reimbursement system, including rate- setting methodologies and reimbursement practices. d. Review of the Board's program for the purpose of certifying its Children's Diagnostic and Treatment Center. e. Review of the Board's program to determine compliance with any of the Standards/Guidelines identified in Attachment A of this Contract. 12. That reviews and/or audits shall be conducted according to the following protocol: a. A mutually acceptable date for the review/audit shall be negotiated. b. The Guideline and/or instrument to be used to review the Board, and the criteria for assessing the Board's performance, shall be provided to the Board at least sixty (60) days prior to the review, unless prohibited by Administrative Rule or Federal regulation. c. The following information shall be provided at least sixty (60) days prior to the date of the review, unless prohibited by Administrative Rule or Federal regulation: 1. A list of documents to be reviewed. 2. Identification of Board staff to participate and an estimate of time required of staff. 3. An estimate of the time required for the review/audit. 13. That all reviews/audits shall provide to the Board: a. An opportunity to discuss and/or dispute any aspect of the preliminary report, prior to dissemination of any report of the review within or outside the Department. b. An appeal regarding findings contained in the final report. This section shall not be construed as preventing the Board from agreeing to work with the Department, on short notice, on an emergency review under extraordinary circumstances. FULL MANAGEMENT CONTRACT FY '96-97 - Page 13 14. That it will insert language in all interdepartmental agreements signed by the Department, and which are intended to describe or govern actions of Community Mental Health Boards, which makes clear that such agreements do not establish a mandate for Board action unless and until included in the Department/Board Contract. Such agreements will include a commitment by the Department to transmit the agreement to the Boards, as reflective of a general policy position by the Department. 15. That it shall be solely financially responsible for all audit exceptions pertaining to State-provided services which occurred prior to Oct. 1, 1992. 16. That nothing in this Contract shall negate the State of Michigan's ultimate Constitutional responsibility to provide appropriate mental health services, in accordance with the provisions of the Michigan Mental Health Code. 17. The Parties finally agree that notwithstanding any other term or condition in the Contract or other applicable agreement between the Parties, the County, as provided for in the Michigan Mental Health Code ("Code"), will have the right to change the current organizational structure of the County Program (currently organized as a "Community Mental Health Agency" as defined in the Code) to that of either a "Community Mental Health Authority"or "Community Mental Health Organization" as also defined in the Code (herein "CMH Organization"). If there is such an organizational change, the County, except as otherwise provided for by the Oakland County Board of Commissioners or the Code, shall have the right to assign, delegate and/or otherwise transfer, without recourse against the County, any and all current County, County Program, County CMH Agency, and/or Board responsibilities and obligations under the Contract and/or any other separate contract or applicable agreement between the Department and either the County, County Program, County CMH Agency ; and/or Board to any such successor CMH Authority or CMH Organization. The Department further agrees that in event the Department's obligations under this Contract or any other applicable agreements between the Parties are transferred by the County to a CMH Authority or CMH Organization, any and all such Department duties and obligations shall be due and owing, without limitation, to the successor CMH Authority or CMH Organization. PART II - STATE-MANAGED SERVICES 1. The Board and the Department agree, for the purpose of establishing full management responsibility, that the Board will serve as the single point of entry and exit for public mental health services to residents of its service area. This ' FULL MANAGEMENT CONTRACT FY '96-97 - Page 14 97FMK A3.WPD Part does not apply to Forensic Center admissions, nor to continued stay in other State-managed services when a court order of NGRI or 1ST is applicable and limits the authority and responsibility of the Board described herein. Mechanisms/procedures for implementation of this single-entry responsibility will be contained in an Operating/Service Agreement between the Board and each hospital/center with which the Board had during the previous year, or anticipates having during the current Contract year, at least 365 days of client service. In addition, agreements will be executed between the Board and each of its admitting facilities. Such facilities shall be identified, with planned service utilization indicated, in Part V of this Contract. 2. Consistent with its role as the single point of entry and exit, the Board will provide, directly or under contract, pre-admission screening for all persons for whom admission to a State-managed hospital or center is sought by any party. Specific procedures for accessing this pre-admission screening shall be contained in the Operating/Service Agreement between the Board and the hospital/center and made available to social services and law enforcement agencies within the Board's area. 3. The Board shall authorize, in advance, all admissions of Oakland County residents, and persons on a "where-found" basis, to State-managed hospitals/centers. Additionally, the Board shall review, and may authorize, continued stay at intervals specified in each Operating/Service Agreement. The authorization of continued stay shall be based upon the continued need of the individual for inpatient or residential service in or through a State hospital/center, and shall be established after review of the clinical status of the individual and consultation with facility staff. 4. The Department and the Board agree that admissions must be medically necessary as specified in Section 401 et seq. of the Michigan Mental Health Code, or that the criteria for judicial admission of a person with developmental disabilities must be met, as specified in Chapter 5 of the Code; that the recipient's condition must be reasonably expected to improve (unlese-there-is-ne OVIErinttel—ff the individual); that inpatient care in a State hospital/center must be the most . appropriate level of care available; and that the recipient must require continuous observation and behavior control under the close medical supervision of a physician. The parties further agree that continued stay will be authorized so long as the requirements for medical necessity are met and the Board cannot implement an alternative at the appropriate level of care. The provisions of the Michigan Mental Health Code shall govern the implementation of this paragraph. FULL MANAGEMENT CONTRACT FY '96-97 - Page 15 5. The Board's authorization of admission and of continued treatment shall be the basis on which the Board will reimburse the Department for the State cost of inpatient or residential services provided in or through a State-managed hospital/ center. The Board's obligation for the local match cost of such services shall not be affected by this Section. Authorizations shall be conveyed in writing to the hospital/center. The Department's Area Manager serving the Board shall be notified by the Board within seven (7) days of the decision when the Board determines that continued inpatient or residential care, or care at the level currently being provided, is no longer warranted based on the criteria stated in item 4 above, but the hospital/center did not discharge the individual. Likewise, the Area Manager will be notified by the hospital/center whenever a request by the Board for continued stay or care at a certain level is clinically unwarranted in the judgement of the hospital/center. Such notification will initiate a process for resolution of the differences. 6. Operating/Service Agreements shall contain a procedure for the review of decisions of the Board regarding authorization for admission or continued inpatient/residential service. Such request for a review shall be entered within forty-eight (48) hours of the contested decision of the Board. Final review shall involve the Director of the Department and the Director of the Board. 7. Notwithstanding provisions of item 1, above, the Board shall continue to plan for services to persons on NGRI and 1ST orders, participating actively with State facility staff with regard to discharge planning. The Board shall make appropriate placement plans for such persons, and update them periodically. PART Ill MANAGED CARE A. Mutual Assurances: The Department and the Board agree that the Board will provide a single point of entry and assume responsibility to manage mental health services beyond the level of mental health service normally provided in the primary physician's office for all Medicaid recipients enrolled in a Physician Sponsored Plan, or who are ncT enrolled in any Medicaid managed health care plan or capitated arrangement. After July 1,1997, Medicaid recipients served through HMO's, Clinic Plans and other Qualified Health Plans will be included. B. Board Assurances The Board agrees to: FULL MANAGEMENT CONTRACT FY '96-97 - Page 16 1. Carry out its responsibilities in accordance with the standards and procedures in Attachment C of this Contract. 2. Conduct pre-admission screening of individuals requesting inpatient psychiatric admission, authorize admission, conduct continuing stay reviews during the inpatient episode, conduct retrospective stay reviews, and authorize Medicaid payment according to the Statewide standards and procedures. 3. Conduct pre-admission screening, assessment, approval of individuals' continuing stay reviews, and Medicaid payment authorization for partial hospitalization services. 4. Coordinate outpatient mental health services with primary healthcare service providers for Medicaid enrollees. 5. Coordinate mental health services with local Substance Abuse Coordinating Agencies through written agreements. 6. Coordinate mental health services for Medicaid recipients with Health Plans under Managed Care, including HMO's, Qualified Health Plans and Clinic Plans, through written local procedures. 7. Ensure that clinically appropriate alternatives to inpatient services are provided. 8. Provide consumers a choice from among a panel of Medicaid-enrolled hospitals. 9. Provide access to services within the following time frames: (a) immediate access to emergency services; (b) screening and referral within seven (7) days for non-emergency tififiiiSei&R—tre--T.ype-24 services; and (c) admission to Type 21 services according to established Board procedures and priorities. 10. Incorporate Medicaid managed care appeals and grievances from recipients and providers into the Board's complaint appeal and grievance processes. 11. Strive to Manage Medicaid expenditures for inpatient psychiatric hospital, • partial hospitalization, Medicaid-billable intensive Crisis Residential care, FULL MANAGEMENT CONTRACT FY '96-97 - Page 17 and Medicaid-billable Intensive Crisis Stabilization services, within the expenditure target established for the Board's elesigneteel-ejeegferthieel twee. Similarte-the-ricAtkbenefit-medel tised-fer-stette-hespitalieenter-serviees i If these expenditures exceed the target cap, the Program shall pay the state share of the excess expenditures from the Program's state authorization. If expenditures are below the target, the Program's state funding authorization will be increased by the amount of the state share saved. Such savings may be redirected by the Program for approved mental health programs. The FY 97 target cap is $3,966,276. The Parties further agree that should the Program exceed the FY 97 target cap, that only funds previously allocated to the Program from either the Department or the County will be used to repay the state and that the Program will only be required to reallocate previously allocated State and/or County funds for repaying the state as provided in this paragraph. Notwithstanding any provision in this section or any other section in this Contract, under no circumstances shall the County be responsible for or obligated to pay to the state or contribute any additional amount to fund the Program so that the Program may repay to the state any excess Program expenditure that exceeds the target cap. C. Department of Community Health Assurances The Department agrees to: 1. Provide a proposed annual expenditure target at least thirty (30) days prior to the first day of each fiscal year, for negotiation with the Board of a mutually acceptable target figure. 2. Monitor compliance with the Statewide standards and procedures contained in Attachment C, as part of the annual process for certifying the Board's Medicaid enrollment. 3. Issue to the Board, no later than September 1, 1997, a report which reviews the Board's performance of responsibilities related to this program and establishes the Department's intent to continue or alter this portion of its contractual relationship. FULL MANAGEMENT CONTRACT FY 196-97 - Page 18 4. Reimburse the Board as provided for in the Master Earned Revenue Contract between the Department and County/Board covering the 1996- 1997 fiscal year. PART IV SPECIFICATION OF SERVICES, FUNDING LEVELS AND RELATED REPORTING REQUIREMENTS The parties agree that the Summary of Projected Funding, which is Part V of this Contract, represents the Board's plan of service and contains the funding commitments of the Department and the Board. A. Total Obligations 1. The parties agree that decisions and actions outside of the terms of this Contract may influence the level of funding included on lines B through F of the Summary of Projected Funding. Changes in this funding which occur during the Contract period will be reported to the Department as part of required Contract amendments. 2. The parties agree that the Federal share of Type 21 Medicaid services will be a reimbursement to the Board and will be deducted from the gross cost of service when determining the net cost of service. It is further agreed that Part V - Funding contains the Board's projections of Medicaid collections. Should actual collections exceed these projections, additional Federal Medicaid will be retained by the Board for its use in improving services, improving service capacity, or restoring base program capacity lost as a result of unfunded economic increases and/or funding . reductions. 3. The Federal and State share of Crisis Residential and Crisis Stabilization services which are eligible for Medicaid reimbursement will be a reimbursement to the Board which is reported on Line II(B) of the Summary of Projected Funding. These funds will be reflected as part of the gross cost of the Board's program, but will not affect the Department's funding obligation. 4. The parties agree to obligate their respective share of funds for matched services in accordance with the Part V - Summary of Projected Funding. The Department's obligation shall be the DCH Maximum Funding Obligation - Matched Services (Section IV, 2 of the Summary of Projected Funding), which is the official funding authorization of the Department. FULL MANAGEMENT CONTRACT FY '96-97 - Page 19 +7FMK A3.WPD The County's commitment shall be its approved Total County Obligation (Section III, of the Summary of Projected Funding). The Department's obligation includes state funds which may be used for specified purposes only. These funds are described in Part V of this Contract entitled CATEGORICAL PROGRAMS. Specifically, the Department agrees to pay the Board, on a net matchable basis, the state share of non-reimbursed expenditures not to exceed the Maximum Funding Obligation - Matched Services which is established in this Contract, for formula funding. The Board has obligated local funds in support of formula funding. The Board, agrees to pay its share of non-reimbursed expenditures, or the balance of formula-funded expenditures, whichever is higher. B. Cash Advances. Including Medicaid Advances 1. The Department agrees to provide the Board with an advance equal to one-sixth (1/6th) of the total Title XIX revenues (Federal and State share) as reflected in the approved Summary of Projected Funding (total of items G-2b plus G-2c plus G-3b plus G-3d), which is Part V of this Contract. This Medicaid advance is provided in addition to the monthly advance of State and Federal funds to the Board described below. This advance does not increase the Department's commitment or establish any additional spending authority in excess of the total amount indicated in the last approved Summary of Projected Funding under the terms of this Contract. 2. This one-sixth (1/6th) Medicaid advance shall be due and repayable to the ' Department by the Board no later than the first day of November for the fiscal year ending the previous September 30th. If the repayment of this advance is made by wire or electronic transfer, the Department will issue a new Medicaid advance for the twelve (12) months beginning October 1st of the current year, no later than one day after their repayment by the Board. If repayment of the advance is made by check, the current-year advance will be forwarded as soon as the • Board's repayment is processed. Failure to repay this Medicaid advance by November 1st will disqualify the Board from any Medicaid advance for the current fiscal year. 3. The amount of this one-sixth (1/6th) Medicaid advanced will be adjusted ' during the Contract year to reflect any change in the total amount of Title FULL MANAGEMENT CONTRACT FY '96-97 - Page 20 XIX Medicaid (State and Federal) revenues in the last approved Summary of Projected Funding which is at least $300,000. Any decrease in this advance will be deducted from the next monthly cash advance to the Board, and the Board will be notified to adjust its Medicaid advance liability accordingly. Any increase to this Medicaid advance will be paid to the Board, and the Board will be notified to increase its Medicaid advance liability. 4. The Department will also provide advances monthly, subject to availability of funds or conditions identified in Parts I and IV of this Contract. The amount of each advance will be determined in accordance with the Board's Summary of Projected Funding. This amount will consist of one- twelfth (1/12th) of Federal Medicaid as reflected in the Contract on lines G-2B and G-3B, plus one-twelfth (1/12th) of the total projected Department funding which includes the State share of Medicaid. These cash advances will be reduced by the amount of gross Type 21 Medicaid and Personal Care Payments (excluding Medicaid-certified Crisis Residential and Crisis Stabilization) received since the previous Department advance of funds. This advance will not be affected by the fiscal year change. The Board's October advances will, therefore, be reduced by actual Medicaid payments made by DSS/DCH during the month of August, and so on. 5. Monthly advances are conditional upon receipt of revisions to the Summary of Projected Funding on April 30 and June 30, the preliminary estimate of accounts payable referenced in Part 1(B)(8), and a final expenditure report by December 31. Failure to authorize payment of undisputed billings for State-operated inpatient and residential services when due will result in delayed advances to the Board. Should the Board fail to pay to the Department the full amount of the one-sixth (1/6th) Medicaid advance by November 1, monthly advances will stop until the amount of the payable has been recovered. FULL MANAGEMENT CONTRACT FY '96-97 - Page 21 C. Obligations for State-Operated Services 1. The Board shall authorize payment, within sixty (60) days of receiving the bill, for the actual number of Board-authorized days of care provided to its residents in State hospitals and centers identified in Part V of this Contract. The maximum funding obligation, by population, is identified as follows: Contract Base Obligation Vulnerability Board Maximum Factor Funding MI ADULTS: Inpatient: 44,775 Days/$ 9,506,640 Residential: 0 Days/$ 0 $ 9,506,640 x1.05 = $ 9,981,972 MI CHILDREN: Inpatient: 2,228 Days/$ 406,607 Residential: 0 Days/$ 0 $ 406,607 x1.05 = $ 426,937 DEVELOPMENTALLY DISABLED: Inpatient: 11,107 Days/$ 1,609,917 Residential: 16,975 Days/$ 1.767.879 $ 3,377,796 x 1.05 = $ 3,546,686 2. Payment for State-operated services shall be made at the full management billing rates shown in Part V of this Contract, based upon a bill which identifies the individuals served and days of care provided at a fixed net State cost per day. The Board's payment for days of care shall cover days provided to specified individuals which are authorized by the Board as described in Part II of this Contract. 3. The Board may withhold payment for days of care provided to specified individuals when any provision of the master Full Management Contract or a hospital/center subcontract is violated with respect to that individual. Payments shall not be withheld until the Board has notified the hospital/ center director of specific areas, related to a specified client, in which the Contract or subcontract has been violated. A copy of this notification shall be forwarded by the Board to the Department's Area Manager within five ' (5) days of the point of non-payment. FULL MANAGEMENT CONTRACT FY '96-97 - Page 22 97FMK A3.WPD 4. The Department commits itself to a good-faith effort to achieve equitable funding for the Board in comparison with other Community Mental Health Boards, based on consideration of per-capita funding and other relevant factors. 5. This Contract shall be reopened and the funding base revised in the event that the Board and/or the Department discovers data which supports such a revision. 6. The Department agrees that when State-managed services are transferred to the Board, the State shall transfer dollars representing the negotiated amount that reflects the costs necessary to operate the program, including but not limited to, administrative and support costs, day programming, transportation, recipient rights protection, public relations costs, one to one staffing, power and other utility costs, exception payments, and day program funding for residential clients. Any and all cost increases, either economic or salary, made to State-managed services or employees shall also be made available to the Board if corresponding funding is appropriated by the State legislature. 7. Changes in State-operated hospitals'/centers' per diem rates will be accompanied by a corresponding change in State allocation to the Board's Contract base. 8. The Board shall have the right to admit its clients to State hospitals/centers outside of its usual catchment areas for persons requiring specialized services not available at Clinton Valley Center or Fairlawn Center, with authorization from the Department. 9. The Board agrees to authorize payment of the County match portion of the net cost of services provided to persons who are its financial responsibility as defined by Section 306 of the Michigan Mental Health Code. Authorization of undisputed bills or undisputed portions of bills will be made within sixty (60) days of receipt of the billing. The Board agrees to identify to the Department disputes concerning bills, on a case-by-case basis, - within sixty (60) days of the bill, and to work with the Department in resolving these disputes on a timely basis. The Department may refer to the Department of Treasury for collection all bills which are both undisputed and overdue. FULL MANAGEMENT CONTRACT FY '96-97 - Page 23 D. Cost Settlement 1. With regard to funds expended for provision of matched services covered by the Summary of Projected Funding, the Department will cost-settle with the Board, subject to Contract limitations, based upon the Board's reported actual net matchable costs. Expenditure of total State funds may not exceed the DCH MAXIMUM FUNDING OBLIGATION - Matched Services. (Part V, Section IV, 2 of this Contract), as included in the Board's final contract amendment. Net matchable costs shall be identified in accordance with general accounting principles and with the Community Mental Health Financing Guidelines published by the Department pursuant to Administrative Rules R.2038 and R.2044, as revised in September 1993 and contained in Attachment A of this Contract. Matchable expenses are subject to audit by the Department or by the Michigan Auditor General. 2. Prior-year cost settlements still subject to Department audit may be re- opened for negotiation in the current year, based on circumstances which shall be submitted by the Board in writing to the Department. The impact of this re-opening will be on the current fiscal year. 3. A preliminary cost settlement based on the Board's final expenditure report will be made forty-five (45) days following receipt of the report. Amounts due the Board will be forwarded at that time; amounts due the Department will be forwarded within sixty (60) days of the Board's receipt of the report. Adjustments as a result of revisions to the Board's final report may be made. FULL MANAGEMENT CONTRACT. FY '96-97 — Page 24 PART V - SUMMARY OF PROJECTED FUNDING CMH BOARD: OAKLAND COUNTY Plan Submission: Original FY 1996/97 [Al LB] [C] [DI - (El In Programs for Programs for Persons with Adults with Children with Developmental Other Board Total Mental Illness Mental illness Disabilities Programs Administration. Expenditures I. Service Summary Estimated Clients Served this Year 7,100 1,300 2,400 10,800 11. Projected Funding Summary A. Projected Gross Funds $54,165,034 $9,572,144 $73,733,296 $5,616,029 $7,282,819 $150,369,322 B. Non-DCH Funds $0 $O $0 SO $50,881 $50,881 C. Local Non-Match Total $879.180 $235,303 $374,855 $O $0 $1,489,338 D. CMH Earned Contract Funds Total $0 $0 $0 $0 50 $0 E. OCH Grants and Earned Contracts Total $549,074 SO $O $1,058.020 SO $1,607,694 F. SAMHSA (Federal) Block Grant $45.000 $57,578 $0 SO SO $102,578 G. Matched Services Total $52,691,780 $9.279,263 $73.358,441 $4,558,009 $7,231,938 $147,119,431 1. State Provided Services Purchase . $6,197,505 5267,180 $3,354,715 SO $0 $9,819,400 2. Services Requiring No Local Match (100% state) a. 1sV3rd/SSI 0 0 40.504 0 0 40,504 b. Federal Medicaid 495.211 3.523 21,158,315 5,248 0 21,662.297 c. State Medicaid 402.398 2,863 17,192.809 4,264 0 17,602.334 d. Other State 8,180.533 1,695,355 955,551 501,441 0 11,332.880 e. Total 59.078,142 51,701.741 539.347,179 $510,953 $O 550.638,015 3. State and Local Match Total (90/10 programs) a. lst/3rd/SSI 243,759 53,375 441,216 6,939 0 745,289 b. Federal Medicaid 5,358.956 395.610 10,428,854 22,445 0 16,205,865 c. Local Funding 3.181,342 686,136 1,978,648 401.767 723,194 6,971,087 d. State Medicaid 4,354.577 321.464 8.474,271 18,238 0 13,168,550 e. Other State funding 24,277,499 5.853,757 9,333.558 3,597,667 6.508,744 49.571,225 (community based fundkig) 1. Total $37.416.133 37,310.342 330,656,547 34.047,056 $7,231,938 $86.662,016 III. TOTAL DCH FUNDING (MATCHED SERVICES) (G 1 G2c • G2d • G3d. G3e) IV. TOTAL MAXIMUM COUNTY OBLIGATION (C9 • G3c) $43,412.512 $8.140,619 339.310.904 54,121,610 56,508.744 5101,494,389 54,060,522 3921.439 32,353.503' 5401,767 $723,194 $8,460,425 FULL- MANAGEMENT CONTRACT FY '96-97 - Page 25 DETAIL SHEET 1 FOR PART V - SUMMARY OF PROJECTED FUNDING SOURCE OF REVENUE DETAIL CMH BOARD: OAKLAND COUNTY Plan Submission: Original FY 1996/97 LINE B - NON-DCH FUNDING DETAIL 1. Substance Abuse 2. DD Council.Project Grant 3. Sheltered Workshop Income 4. Other: IGT Transfer 50,881 5. Total: $50,881 LINE C - LOCAL NON-MATCH 1. Non-match expenditures 2. Local share - DCH grants/earned contracts 3. Local share - Non-DCH Grants/earned contracts 4. Non-approved programs 5. Excess local - P.A. 423 related 6. Excess local - other 7. Local share - SAMHSA federal grant 8. Other: 100% County Funding for Children's Wraparound 198,803 9. Local share - state provided services 1,290,535 10. Total $1,489,338 LINE E - DCH EARNED CONTRACT DETAIL 1. AGENCY: OBRA PASSAR AGREEMENT a. Federal Medicaid b. 1st/3rd/SSI c. Other 1,058,020 2. AGENCY: MEDICAID MANAGED CARE EARNED CONTRACT a. Federal Medicaid b. 1st/3rd/SSI c. Other 429,211 LINE E. - DCH PROJECT GRANT DETAIL 3. Project Grant Funding: PATH Homeless Assistance Grant a. Federal Medicaid b. 1st/3rd/SSI c. Other 119,863 4. Total • $1,607,094 LINE G. 3.C. SERVICES REQUIRING 10% MATCH - LOCAL FUNDING 1. XX Replacement 75,409 2. Other Local 8,385,016 3. Total (corresponds to G.3.c) $8,460,425 MATCHED SERVICES TOTAL MEDICAID (FEDERAL AND STATE SHARE) 1. ICF - MR (ais) 2. Personal Care 5,583,536 3. H.C.B. Waiver 16,069,873 4. Clinic Serv. (Inc CSM) 19,884,354 5. Other - AIS 26,361,284 6. Other - Child Model Waivers 740,000 7. Total $68,639,047 OBRA* OBRA TREATMENT PLACEMENT** 95/96 CARRY 96/97 FORWARD ETHNIC • 12/17/96 $516,827 450 574,252 516,827 12/17/96 $634,409 20 665,139 634,409 FULL MANAGEMENT CONTRACT FY '96-97 - Page 26 DETAIL SHEET 2 FOR PART V - SUMMARY OF PROJECTED FUNDING CATEGORICAL PROGRAMS CMH BOARD: OAKLAND COUNTY Plan Sybmission: Original FY 1996/97 (A) PROGRAM TITLE 94/95 MODEL II TOBACCO TAX WAIVERS RESPITE (B) DCH AUTHORIZATION LETTER DATED (C) DCH FUNDING AUTHORIZATION (D) ESTIMATED CLIENTS SERVED THIS YEAR (E) PROJECTED GROSS EXPENDITURES (F) PROJECTED STATE EXPENDITURES (A) PROGRAM TITLE 12/17/96 $800,000 10,800 888,889 800,000 95/96 5% IN-HOME RES. ECON. 12/17/96 $100,000 40 116,056 100,000 93/94 RECIPIENT RIGHTS (B) DCH AUTHORIZATION LETTER DATED (C) DCH FUNDING AUTHORIZATION (D) ESTIMATED CLIENTS SERVED THIS YEAR (E) PROJECTED GROSS EXPENDITURES (F) PROJECTED STATE EXPENDITURES 12/17/96 $331,742 29 740,000 331,742 12/17/96 $150,000 200 385,000 346,500 12/17/96 12/17/96 $191,445 $12,000 231 10,800 502,928 100,000 502,928 90,000 FULL MANAGEMENT CONTRACT FY '96-97 - Page 27 DETAIL SHEET 3 FOR PART V. SUMMARY OF PROJECTED FUNDING PLANNED STATE SERVICES UTILIZATION CMH BOARD: OAKLAND COUNTY Plan Submission: Original FY 1996/97 Contract Planned State Contract AGENCY Days Rate Amount A. Caro Regional Center (MI) 1. MI Adult Inpatient 2,555 252.00 643,860 B. Clinton Valley Center 1. MI Adult Inpatient 19,165 214.00 4,101,310 C. Detroit Psychiatric Institute 1. MI Adult Inpatient 0 261.00 0 D. Kalamazoo Regional Hospital 1. MI Adult Inpatient 730 211.00 154,030 E. Northville Regional Hospital 1. MI Adult Inpatient 2,555 230.00 587,650 F. Walter Reuther Facility 1. MI Adult Inpatient 4,015 177.00 710,655 G. TOTAL MI ADULT 29,020 $6,197,505 TOTAL MI ADULT INPATIENT 29,020 $6,197,505 H. Detroit Psychiatric Institute 1. MI Children Inpatient 0 235.00 0 I. Hawthorn Center 1. MI Children Inpatient 1,460 183.00 267,180 J. KRPH - PRC 1. MI Children Inpatient 0 326.00 0 K. TOTAL MI CHILDREN 1,460 $267,180 TOTAL MI CHILDREN INPATIENT 1,460 $267,180 L. Caro Regional Center (DD) 1. DD Inpatient 6,570 142.00 932,940 2. DD AIS 1,095 102.00 111,690 3. DD Other Comm. Residential 3,285 141.00 463,185 M. Mt Pleasant Center 1. DD Inpatient 2,190 154.00 337,260 2. DD AIS 7,665 97.00 743,505 3. DD Other Comm. Residential 7,665 92.00 705,180 N. Southgate Center 1. DD Inpatient 365 167.00 60,955 0. TOTAL DD 28,835 $3,354,715 1. TOTAL DD INPATIENT 9,125 $1,331,155 2. TOTAL DD AIS 8,760 $855,195 3. TOTAL DD OTHER COMM. RES. 10,950 $1,168,365 GRAND TOTAL 59,315 $9,819,400 FULL MANAGEMENT CONTRACT FY '96-97 - Page 28 PART VI OPERATING PROCEDURES A. Financial Management Procedures 1. Accounting and Auditing and Standards. Principles and Procedures Expenditure reports shall reflect the accrual of client-based revenues. The following documents should guide Board accounting procedures: a. Governmental Acc unting and Financial Reporting Standards, third edition of May 31, 1990, published by the Governmental Accounting Standards Board. b. Audits of State and Local Governmental Units issued by the American Institute of Certified Public Accountants in 1989. c. Federal Office of Management and Budget Circular A-87, Cost Principles for State. Local and Indian Tribal Governments. 2. Fiscal Auditing a. The Board will ensure that a fiscal audit of each of its contractual service agencies identified by the Board and the Department is performed. Results of such audits shall be submitted to the Department, if requested. b. The Board agrees to permit the Department to conduct an annual financial audit of the Board's fiscal records and/or submit an independent audit for this Contract period. B. Contract Attachments The documents listed in Attachment A, B and C, as provided to the Board, are a part of this Contract unless specifically abridged in writing and agreed to by the parties. Such documents shall be provided to the Board with the Department's contract proposal and initial funding authorization. FULL MANAGEMENT CONTRACT FY '96-97 - Page 29 Signatures: , Date: ,1997 John P. McCulloch, Chairperson Oakland County Board of Commissioners , Date: , 1997 Fran Amos • , Chairperson Oakland County CMH Services Board , Date: , 1997 Sandra M. Lindsey, Executive Oakland County CMH Services Board SERVANCEDZIREERESMENNEMBENSIERTEsagammaleMTMESPIEM , Date: ,1997 James K. Haveman, Jr., Director Michigan Department of Community Health A-1 Attachment A Page 1 COMPLIANCE WITH PROGRAM AND FISCAL STANDARDS The Oakland County Community Mental Health Services Board agrees to comply with the provisions of the program and fiscal standards listed below. Should a program or board be determined to be in non-compliance, in whole or in part, with a standard identified in this Attachment, the board will be notified in writing of the specific area(s) of non-compliance and documentation for the allegation. The board shall respond to such notification within 45 days in one of the following ways: A. Presentation of facts which dispute the allegation. B. A plan of correction for achieving compliance. C. A request for waiver, for a specified time period, of the standard, accompanied by a plan for compliance. The department shall respond to the board within 30 days. In no case shall an allegation of non-compliance with standards be considered the single grounds for non-compliance with the contract until all opportunities for exercise of appeal of the allegation have been exhausted. 1. CMH Specialized Residential Programs (October 1992), as attached to this contract. 2. Community Mental Health State Financing (September 1993), attached. 3. Michigan's Mission Board Performance Indicator System 1.0, attached to this contract. 4. Agreement Regarding CI H Board Policy on Review and Reporting of Death (October, 1992), attached to this document. 5. Behavior Management Committee, as attached to this contract. 6. 01-C-1116(i)/AD-01, Administrative Directive FY 83/84 IV-C-20 (May 22, 1984), Criteria Concerning Utilization of Certain Community Residential Facilities. 7. 01-C-1116(j)/AD-10, Administrative Directive III-C-22/IV-C-25 (February 8, 1990), CMH full Management Board Earned Contracts for Specialized Residential and Support Services (Optional). 8. 02-R-2006/GL, Department of Mental Health Guideline IV-C-003- 000]. (June 3, 1983), Agreements Between Nursing Homes and CMH Boards for Mental Health Services. A- 2. 9. 02-R-2007/GL-00, Department of Mental Health Guideline IV-H- 007-0001 (December 21, 1982), Continuation and Transfer of Demonstration Projects. 10. 03-C-1311/GL-01, Department of Mental Health Guideline IV-F- 001-0003 (September 27, 1989), Community Mental Health Grant Fund. 11. 07-C-1722/AD-004, Supplemental to Administrative Directive FY 82/83 IV-G-3 (May 18, 1984), Adult Protective Services Act - DSS/DMH Agreement. 12. 07-C-1738/AD, Administrative Directive FY 82/83 IV-G-4 (September 6, 1983), Notification to School Districts and Provision of Pertinent Information when a School-Aged Resident is to be placed in a Community Setting. 13. 07-R-7158/GL, Department of Mental Health Guideline III-H-003- 0006 (September 26, 1985), Medication Use: Psychotropic - Drugs. 14. 07-R-7165/GL, Department of Mental Health Guideline IV-H-005- 0002 (July 2, 1985), Food and Dietary Practices, Policy Only. 15. 08-C-1812/AD, Administrative Directive IV-F-7 (March 29, 1985), Optional Method for Recovery of Supplemental Security Income Retroactive Payments. 16. 07-C-1708/GL-05, Housing. 17. 01-C-116(J)/GL-01, Inclusion. 18. Consumerism Guideline (June 1996), as attached to this contract. 19. Personal Care in Non-Specialized Residential Settings (1996) as attached to this contract. CMH SPECIALIZED RESIDENTIAL PROGRAMS It is the policy of the Department of Mental Health to provide funding in accordance with Public Act 258 of 1974, as amended, for community mental health (CMH) operated or conti-acted residential services when such services meet requirements established in the master contract and this document. Residential programs should be organized and carried out to meet specific client oriented goals established by the board consistent with general DMH policy. This policy includes movement toward smaller, more community integrated settings than is permitted within the traditional group home structured program model. These goals must incorporate principles of client choice and the rights of all persons to participate as much as possible in the life of their communities. Except for residential services provided directly by a board, all specialized residential and residential support services shall have a binding contract. It shall be signed by the provider and the CMH board director. Community mental health boards may not utilize contracts or forms developed by the Department of Mental Health. I. GENERAL REOUIREMENTS FOR ALL RESIDENTIAL PROGRAMS The following requirements apply to all residential programs: A. Size of Homes: New contracts for specialized mental health services may not be written on behalf of more than six (6) adult recipients in any licensed setting. Exceptions to this standard are permissible when placement of a client in a setting of seven (7) to sixteen (16) beds is clinically indicated and appropriate in the judgment of the CMH director, or for semi- independent programs such as apartments and the Fairweather Program. No home shall serve more than four (4) non-ambulatory persons without prior written approval of the director of the CMH Bureau. Such approval will be granted only with the explicit agreement that sufficient staff and other resources will be available to provide for the safety and other needs of the recipient. B. Number of Homes Per Provider: Community mental health boards must have a policy regarding the number of homes which can be under contract with a single contractor. This policy should reflect the board's decisions A-4 Attachment A Page 5 regarding protection of the program against circumstances in which a single contractor may cease business. C. Reimbursement: It is the responsibility of the Responsible Mental Health Agency CRYLHA) to ensure collection of all reimbursements for which clients are eligible. To secure federal financial participation for personal care services or other programs eligible for federal reimbursement, the RHEA must ensure that the recipient and financial information required as a condition of reimbursement is maintained for a minimum of seven (7) years. D. rood Stamps: No provider may require a resident to apply for food stamps as a condition for receiving services. Providers may not require that recipients surrender food stamps to the provider. E. Personal Allowance Fund: Community mental health boards shall have specific policy regarding accounting for and monitoring personal allowance funds, which accomplishes the following goals. 1. Recipients of service should assume responsibility for their own funds unless there is a legal determination to the contrary or the client chooses to do otherwise. The recipient's choice must be documented. If the recipient is unable to exercise choice and provider management is requested, the guardian must assent in writing. 2. Restrictions shall not be placed upon the recipient's handling or expenditure of personal funds unless there is a specific written plan developed by the clinical staff of the responsible agency. 3. Upon receipt of personal allowance funds which are to be managed by the provider, whatever the source, the provider shall both maintain the funds and account for their disbursements separate from funds received for reimbursement for care and program. Funds are to be used at the discretion of the recipient, representative payee or guardian. 4. Personal allowance funds are not to be used for personal care items that are basic to the provision of room, board and supervision that are included in the per diem provided for room, board and A- 5 Attachment A Page 6 supervision and are required by licensing standards (e.g., shampoo, toothpaste, soap, food). F. Conflict of Interest: The CMH shall have policy regarding conflict of interest which is binding on residential providers and their staff as well as members of the provider's Board of Directors, if applicable. This policy shall include a provision that such persons shall not engage in activities which are incompatible or in conflict with the discharge of their duties and responsibilities under the contract. G. Fire Safety Requirements: 1. Adult Foster Family Care and Adult Community Living Facilities. The RMHA shall ensure that residents are trained to evacuate the home in case of fire and that the home meets applicable fire safety standards. Foster family care homes shall have, at a minimum, battery-operated smoke detection equipment, at least one each, in the following locations: a. Between the sleeping areas and the rest of the home. In homes with more than one sleeping area, a smoke detector shall be installed to protect each separate sleeping area. b. On each occupied floor, in the basement, and in areas of the home which contain flame or heat producing equipment. Smoke detection equipment shall be operational at all times. Battery-operated equipment shall have the batteries replaced in accordance with the recommendations of the alarm equipment manufacturer. Detectors shall be tested and examined as recommended by the manufacturer. H. Transportation shall be provided recipients as necessary to meet client goals. Transportation programs shall adhere to requirements for adequate liability insurance, safety to the recipients and proper maintenance of the vehicle. I. Representatives of the Protection and Advocacy system shall be granted access to records of persons with A-6 Attachment A Page 7 developmental disabilities and persons with mental illness consistent with the provisions of Section 748 (7) of the Mental Health Code if both of the following apply: 1. A complaint has been received on behalf of the recipient. 2. The resident does not have a legal guardian, or the state or its designee is the legal guardian. J. If the contract concerns an adult group home setting and is written on behalf of persons with developmental disabilities or persons who are developmentally disabled and mentally ill the contractor shall allow authorized ARC/Michigan (ARC/M) and its local chapter volunteers and staff access during reasonable hours and with reasonable frequency to the grounds, building, program, staff and recipients of service. K. Specialized services which include room, board and 24- hour supervision must be provided in a setting licensed by DSS, unless the resident or resident's family is the owner or lease holder of the setting. L. If a board executes a contract with a residential services provider which is also the owner or lessee of the property, the board must have a written plan for relocation of residents in the event the service provision agreement is terminated. M. The Board shall ensure that all persons providing direct care to recipients of specialized residential services are appropriately trained. Training shall meet the requirements for licensure and for certification of residential facilities, and shall include the training necessary to support the health, safety and well-being of the consumer as well as to carry out the consumer support and/or treatment goals and objectives contained in the consumer's Individual Support Plan or Individual Plan of Service. II. GENERAL REQUIREMENTS FOR RESIDENTIAL CONTRACTS Community mental health boards contracting for specialized residential services may not use the contracts developed and issued by DMH. Board-developed contracts shall, at a minimum, clearly state the agreement regarding: A. Services to be provided, including the program services to be provided to each recipient including the objective of service as indicated in the Individual Plan of Services. Attachment A Page 8 B. A description of their person(s) to be served. C. The time period of the contract. D. The method for making the payment. E. The amount of payment F. Responsibility for application for and collection of reimbursements and entitlements on behalf of recipients including personal allowance funds. G. Appropriate standards of care and insurance of quality, including the provider's responsibility for maintaining licensure and certification. H. The selection of recipients for services. I. Contract termination. J. Development and maintenance of recipient records. K. Nondiscrimination with respect to employment and provision of services. L. Ownership and access to fiscal, administrative and recipients' clinical case records by both parties. M. A procedure or policy regarding payment for days when the resident is absent from the home. This procedure or policy shall ensure that payment for leave days is not required when leave assumptions are accounted for in the charge. Community mental health boards may purchase residential services utilizing either a fee-for-service or a cost settled approach. The funding level for both fee for service and cost settled contracts should be based on the cost of room, board and supervision plus mental health programming costs, difficulty of care allowances and pharmacy costs. The amount received by the provider from the resident or resident's guardian for room, board and supervision (e.g., SSI) must be deducted from a per diem payment by the RMHA. The basis on which the amount of provider payment is ascertained must be documented in records of the RMHA. The basis for cost settlement between the RMHA and the provider, if applicable, must be described in such a contract and records maintained regarding the actual cost settlement. A-8' Attachment A Page 9 III. FUNDING LIMITATIONS The funding structure established by the Board should be based upon the personal care needs, supervision and program needs of , the residents. These needs, as documented in each residents' Individual Plan of Service should directly relate to the staffing requirements of the program and consequently the staff component of the program cost. It is expected that residential providers will maintain records regarding cost which meet general accounting standards. Attachment A Page 1 CMH State Financing (October 1996) I. SUMMARY: To establish standards regarding the eligibility of community mental health program expenditures for state financing. II. APPLICATION: All community mental health services operated directly by or under contract with a Community Mental Health Services Program(CMHSP). III. POLICY: A. State financing as specified in the Mental Health Code is provided through the allocation of the available appropriation for the net cost of community mental health services. B. 100% state financing is provided for the net matchable costs of certain programs approved by the Legislature. C. Only expenditures that are considered legal, prudent and ethical and which conform to DCH policy will be considered for state financial support. 1. Measures by which prudent is determined include: - evidence of careful management with consideration to economy. - offer value to the community mental health services program. - not obviously and manifestly extravagant. - providing a discernable benefit to the community mental health services program, in relation to cost. - contributing to the established outcomes of the • Community Mental Health Services Program. - consistency with standards of comparability. - reflecting consideration of alternatives and a conscious choice from those alternatives. - representing the less expensive option for similar or the same outcomes or products. - comparability to the expenditures of other CMHSP or entities for similar outcomes or products. A-1 0 Attachment A Page 2 2. Measures by which ethical is determined: - conforming to the standards of conduct of an applicable professional group. - expenditures have not been rejected as improper and based on subsequent audit, have been made for purposes related to the legitimate performance of approved mental health program. conformance with the policies of the community mental health services program. 3. Legal is determined by whether practices conform with law and applicable administrative rules. 4. Measures by which policy conformance would be determined - conform with contractual requirements. - conform with requirements Of the certifying body of the CMHSP. D. The purpose of these standards is to establish the eligibility of community mental health program expenditures for state funding. A CMHSP may request and negotiate waivers. A CMHSP may appeal findings of non-compliance using the appropriate appeal procedures as identified in Administrative Directive 01-C-1116(h)AD-01, Audit Resolution & Review (October 11, 1994). IV. DEFINITIONS A. Net Cost - Net cost is equal to the gross cost of all programs less: 1) the costs of non-approved programs, 2) nonmatchable costs, 3) the portion of matchable approved program costs financed from other state or federal funds, 4) fees (except fees collected under the provisions of P.A. 423) and local funding as applicable under standards V-A-1, Local Funding, collected from individuals, relatives, or third-party payers for services provided by the CMHSP and by agencies contracting with the CMHSP for the net cost of services, and 5) other amounts earned by the CMHSP in providing services. B. 100% State Funded Proarams 1. Specialized residential services established by or transferred to the CMHSP after March 31, 1981, in accordance with provisions of Act 423, P.A. of 1980 (Section 309 of the Mental Community Health Code). To qualify for 100% state financing, the specialized residential services must: a. Have previously been under contract with the Department of Community Health (DCH) and transferred to the CMHSP Attachment A Page 3 after March 31, 1981; or b. Have been established or have increased the capacity in existing homes after March 31, 1981, and be administered under the authority of the CMHSP in accordance with Chapter 2 of the Mental Health Code; and c. Have been approved by DCH through the CMH allocation process and operated in conformance with the policies, standards and guidelines referenced in the DCH/CMH contract. 2. Programs for which responsibility is transferred to the CMHSP and the state is responsible for 100% of the cost of the programs, consistent with the Michigan Constitution. 3. Other programs specifically approved for 100% state financing. V. $TANDARDS: A. Local Funding 1. Local funds include: a. Appropriations of general county funds to the CMHSP by the county Board of commissioners; b. Appropriations of funds to the county mental health services program or its contract agencies by cities or townships; funds raised by fee-for-service contract agencies as part of the agency's contractual obligation, the intent of which is to satisfy and meet the local match obligation of the CMHSP, as reflected in the operative master contract between the CMHSP and DCH, provided that the funds are raised consistent with A.2 .a. c. Grants, bequests, donations, gifts from local nongovernmental, charitable institutions, or individuals. Gifts which specify the use of the funds for any particular individual identified by name or relationship may not be used as local match. d. Funds of participating CMHSP's from the community mental health grant fund consistent with Section 226a of the Mental Health Code. e. Interest earned on funds deposited or invested by or on Attachment A Page 4 behalf of the CMHSP; f. Interest earned on DCH funds by agencies as specified in their contracts with the CMHSP to provide mental health services on a net cost basis can be used to fund local match; g. Revenues from other county child care funds) and from districts for CMHSP mental the source of the revenues funds; departments/funds (such as public or private school health services, as long as is not federal or state h. Revenues in excess of expenses for CMHSP mental health and non-mental health services provided by persons other than recipients to agencies/businesses other than those identified in V-A-1-g, as long as federal or DCH state funds are not paid to and/or used by the CMHSP to pay for any costs, including administrative costs of those mental health services. CMHSP's should be expected to comply with IRS and Unrelated Business Income Tax regulations and should seek the appropriate legal opinion as needed. 2. Local funds exclude grants or gifts received by the county, the CMHSP, or agencies contracting with the CMHSP from an individual or agency contracting to provide services to the CMHSP. An exception may be made, where the CMHSP can demonstrate that such funds constitute a transfer of grants or gifts made for the purposes of financing mental health services, and are not made possible by CMHSP payments to the contract agency which are claimed as matchable expenses for the purpose of state financing. B. Nonmatchable Programs 1. Programs which are considered the responsibility of other state, federal or local agencies and are not matchable for state financing. Such programs include special education services and substance abuse services except for DCH- approved Dual Diagnosis programs. 2. The cost of programs/services provided by the CMHSP or agencies contracting with the CMHSP which are wholly or in part financed by other federal or state agencies, are not matchable unless approved by DCH for state financing. Programs included in the CMHSP's annual program description Attachment A Page 5 are approved unless disallowed by DCH in writing. CMHSPs may request approval from DCH on specific programs at any time. If DCH does approve such programs for state financing, the financing provided by other state or federal agencies shall be indicated as revenue and deducted from the cost of services to determine the matchable cost. The basis for DCH funding is the percentage of gross program costs attributable to mental health. 3. CMHSP expenses and revenues for the operation of an AIS/MR program under an earned revenue contract with a DCH facility are nonmatchable. The local portion of the net cost of these services is billed to the counties in the same manner as inpatient costs, or services provided by DCH. 4. The costs of nonmatchable programs are reported as nonmatchable expenditures in determining the amount of state financing for community mental health programs. Any revenues received by the CMHSP in providing nonmatchable programs are not reported in determining the net cost of matchable programs, but are reported separately as revenues received for nonmatchable programs. 5. The cost of any nonmatchable program must include an appropriate distribution of CMHSP indirect costs with the exception of grants from DCH. C. Required Contract Provisions with Aaencies Providina Client Services - The CMHSP may enter into fee-for-service or net cost contracts. Contracts for AIS/MR services may be on a fee-for-service or net cost basis. The CMHSP will be required to cost settle the entire program with the Medicaid State agency. 1. Fee-for-Service Contracts. Fee for service contracts shall include a rate per unit of service based upon CMHSP budgeted costs for providing the service, competitive bids, or an average of local provider rates for like services. Such contracts do not require cost settlement. a. In establishing contract rates, indirect, including administration costs, are allowable only for the percentage that is directly attributable to CMHSP service delivery. b. The rates charged by the provider should not be greater than the lowest rate paid by any other user of the provider's services of the same intensity to meet the Attachment A Page 6 same severity of needs of clients. However, a higher rate can be justified based upon clinical need or the low volume of services used in comparison with other users. 2. Net Cost Contracts. The CMHSP may contract:- with providers on a net cost contract basis as defined by IV-A. The contract should be on a net cost basis as defined in this document and provide for cost settlement, in accordance with this document. All net cost contracts must meet the same requirements as services provided directly by the CMHSP. 3. Vouchers a. Vouchers issued to consumers for the purchase of treatment services provided by professionals may be utilized in non-contract agencies which have a written referral network agreement with the Board that specifies credentialing and utilization review requirements. The agreement must contain provisions for compliance with recipient rights and treatment dispute mechanisms. Voucher rates for such service shall be pre-determined by the CMHSP using actual cost history for each service category and average local provider rates for like services. b. Voucher arrangements for purchase of consumer directed supports delivered by non-professional practitioners, may be made through a cost settled contract or fee for service arrangement. Provisions for compliance with recipient rights and treatment dispute mechanisms shall be included. 4. Other Contracts If any costing and/or settlement is based upon any method other than those listed in 1. and 2. and 3. above, the method must: a. be specifically approved in writing by DCH prior to implementation; b. be supported by acceptable accounting methods. 5. Criteria for Identification of _CM-1SP Clients All Contracts shall specify the criteria for determining whether the clients of the contract agency are clients whose services are chargeable to the CMHSP pursuant to the Attachment A Page 7 contract. 6. Collections from Third Party Payers All Contracts shall specify which party is responsible for determining client eligibility and applying' for benefits; and for billing and collecting from insurers, Medicare or Medicaid, when the agency is a qualified provider and the client is eligible for those benefits. The cost of services which could have been funded from other sources including insurers, Medicare, and Medicaid, will not be matchable for state financing. D. Minimum Administrative Reauirements for State Financing 1. Standards for Medicaid Mental Health Services Programs operated by the CMHSP and its contract agencies must be in substantial compliance with applicable Medicaid Mental Health Clinic Standards. 2. Equipment Inventory and Disposition The CMHSP must maintain written policies/procedures for the control and disposition of equipment items purchased with CMH funds. Such policies/procedures must similarly require net cost contract agencies to inventory and dispose of equipment. The reasonable value of any items sold, traded, or transferred for other than local or state mental health program use shall be subtracted from net matchable costs in determining state financing. 3. Audits and Compliance Reviews of Providers Under Contract or Accepting Vouchers The CMHSP is responsible for assuring that all agencies under contract to the CMHSP comply with the provisions of their contract and with those DCH policies and procedures contained in the CMH/DCH contract. The CMHSP shall assure that agencies under net cost contract with the CMHSP to provide services in the previous fiscal year have been audited for fiscal and contract compliance. This requirement does not apply to: a. Net cost contract agencies with a gross budget under $500,000 are subject to fiscal audit at intervals not to exceed three (3) fiscal years. Audits of such agencies shall cover all fiscal years since the previous audit. In choosing to exercise this option, Attachment A Page 8 it is explicitly understood that the CMHSP retains responsibility for the state share of any funds owed to the department. b. Agencies under a fee for service contract or a referral network agreement accepting vouchers shall be reviewed for compliance with the terms of the contract/agreement and utilization data. Residential service contract providers shall be audited according to the standards contained providing services in licensed settings in the DCH/CMHSP contract. c. State matching funds for the costs of fiscal audits of contract agencies are contingent upon the following: 1) Fiscal audits must be conducted by individuals with at least two years of experience in accounting, or auditing of private or public agencies. Audits may not be conducted by employees of a contract agency for that contract agency. 2) The audit shall specifically address the contract agency's compliance with generally accepted accounting principles and the terms of the contract with the CMHSP for the previous state or CMHSP fiscal year, including the accuracy of expenses and revenues reported to the CMHSP; d. Costs for the special audits of CMHSP contract agencies are matchable if approved by the CMHSP and DCH. 4. Records Retention The CMHSP must maintain, via hard copy or electronic storage/imaging, in a legible manner, financial and clinical records necessary to fully disclose and document the extent of services provided to recipients. The records are to be retained for a period of seven (7) years from the date of service regardless of any change in ownership or termination of service for any reason. This requirement is also extended to any."-CMHSP contract agencies. E. Limited Expenditures for Avoroved Matchable Proarams. The following expenditures are matchable for state funding only when the specified criteria are met. 1. Retroactive Pay Settlements are matchable when they were entered into in good faith during a previous fiscal year up to the amount encumbered for these purposes. Attachment A Page 9 2. Certain community mental health services program (CMHSP) expenditures are considered matchable for state funding when the CMHSP has a written policy that addresses the specific category of expenditure. Policies must be available and must be followed in order for the expense to be matchable. All such policies must be: approved by the governing body of the CMHSP; consistent with the state Mental Health Code, applicable county(ies) regulations, and federal Internal Revenue Service regulations; and consistent, with the specific minimum requirements identified below. a. Per Diem Payments - policy must define persons to receive payments, identify per diem expenses covered, and specify limitations on payments. b. Staff Recruitment Costs - policy must define eligible staff, specify covered costs, and identify limitations on costs. c. Staff Compensation - all components of staff compensation must be defined in an ongoing written compensation plan which must be approved in advance. This includes one-time pay settlements or adjustments. d. Purchasing - policy must include conditions for purchasing including requirement for public ownership of any purchases, and mechanisms for purchasing including approval, bidding, and selection processes, and procedures for purchasing. e. Professional Organization/Society Costs - policy must include definition, conditions (including a requirement that costs are not matchable if they only benefit the professional and not the CMHSP), and procedures. f. Professional Liability Insurance Costs - policy must include definition, conditions (including a requirement that insurance costs for services provided to consumers other than consumers of the CMHSP or a contract agency are not covered), and procedures. 3. Reserve Accounts - Such accounts may be established for the purpose of securing funds needed to meet expected future expenditures for the indicated purpose of the account. Accounts must be established by CMHSP policy which addresses all of the following: a. All programs of the CMHSP shall be charged their proper share of the costs. Attachment A Page 10 b. The reserve must be maintained in an account separate from other operating funds. c. The reserve must restrict the use of the funds to the defined purpose. Such purposes are identified in the Mental Health Code. Reserves for equiraent may be established only by CMHSPs with Authority status. All expenses, for the purposes intended to be financed from the reserve, must be made from this fund. No expenses from this fund will be matchable, only the contribution to the fund will be matchable. No other expenditures may be made froM the reserved funds. CMHSPs with current equipment fund accounts consistent with guidelines in effect in FY 96, have until September 30, 1997 to liquidate those accounts or to achieve authority status. d. The CMHSP must define a procedure for increasing deposits to a reserve account in the event that the reserve becomes inadequate to meet expected future expenditures. e. Deposits to the reserve account must be based upon a reasonable determination of need such as actuarial determination, actual vested level, etc. If the reserves proved to be excessive, the contribution must be reduced to correct the reserve within one fiscal year. Any excess amount will be remitted to MDCH. f. When the reserve account is dissolved, any remaining funds must be used to reduce the reported expenses of the CMHSP after all liabilities of the plan are paid. 4. payments of Legal Claims Certain payments of legal claims against CMHSP's are considered matchable for state funding when the payments are for out-of-court settlements, quasi-judicial resolutions, or resolutions in advance of, during, or after governmental hearings involving claims against the CMHSP when the payments are made based upon advice provided to the CMHSP by the county prosecutor, county corporate counsel, or CMHSP counsel. 5. Network Formation Expenditures related to formation and operation of networks of CMHSP's intended to improve efficiency or prepare for risk based financing mechanisms are matchable when DCH has been notified and has approved any agreements prior to entering into agreements. Notification shall include a copy of the agreement. Attachment A Page 11 F. Nonmatchable Expenditures for Approved Matchable Proarams 1. Applicability - These standards identify expenditures which are considered not matchable for state funding. Unless otherwise specifically identified, these standards apply to: a. expenditures for services provided directly by the CMHSP; b. expenditures by the CMHSP to agencies contracting with the CMHSP to provide mental health services on a net cost basis. c. expenditures by the CMHSP to agencies contracting with the CMHSP to provide mental health services on a fee- for-service basis, where the CMHSP anticipates providing half or more of the agency's revenue. d. These standards for non-matchable costs do not apply to standard flat rate (Type A) residential contracts, • state facility contracts, and fee-for-service where the CMHSP is contracting to pay for less than half of the services of the agency. 2. Nonmatchable Costs a. Rental, lease, lease/purchase, purchase and actual ownership costs in excess of fair market/rental value as referenced in Sections 241, 242, and 313 of the Mental Health Code. The CMHSP shall determine fair market value based upon an independent appraisal from a licensed appraiser. If appraisals are not readily obtainable, the CMHSP shall determine fair market value based upon comparisons of costs for similar structures in the market area. CMHSP's must supply comparative cost figures upon request of DCH. Upon request by the CMHSP, DCH will provide criteria utilized by the Michigan Department of Management and Budget in establishing state facility leasing costs in the area. b. Rent paid to the county by CMHSP's for county-owned facilities that exceed fair market rental as defined in 2.a. and costs of administrative support services provided by the county to CMHSP's for purchasing, accounting, facility maintenance, and other functions of the CMHSP, when the costs the county charges either directly or through an indirect cost plan, exceed the cost CMHSP's would incur for these same services if provided directly by the CMHSP or through independent contract by the CMHSP. Expenses to finance facility construction are matchable in accordance with the Attachment A Page 12 guidelines defined in 2.a. (above) for fair market/rental value. c. Fees incurred by the contract agency for legal services for actions initiated by the contract agency against the CMHSP and/or the state, or for acfions initiated by the CMHSP against the state. Also, fees incurred to defend against suits from other state agencies. d. Amounts for services provided to individuals which could reasonably have been collected from or billed to consumers, or third party payers. e. Interest and penalties from governmental units for nonpayment, or late payment of liabilities (i.e., failure to submit quarterly tax reports), except if the late payment is due to delays in DCH payments to CMHSP. f. Expenditures by CMHSP's to purchase any good or services that were initially developed by another CMHSP using state-matched funds are not matchable. 3. Reporting of Costs for State Financing Nonmatchable costs of approved matchable programs shall be reported as nonmatchable expenditures on expenditure reports submitted to DCH. Michigan Mission Based Performance Indicator System - 1.0 Purposes 1. Clearly delineate the dimensions of quality which must be addressed by the Public Mental Health System as reflected in the Mission statements from Delivering the Promise and the needs and concerns expressed by consumers and the citizens of Michigan (i.e., ACCESS, EFFICIENCY, & OUTCOME) 2. Develop a state wide aggregate status report to address issues of public accountability (including boilerplate requirements required by the legislature, legal commitments under the Michigan Mental Health Code, etc.) for the public mental health system; 3. Provide a mechanism and focus to assist DCH's contract management of local service delivery agreements which will impact the quality of the service delivery system state wide through the identification of both provider requirements and performance indicators; 4. To the extent possible, facilitate the development and implementation of local quality improvement systems; and 5. To link with existing health care planning efforts and establish a foundation for future quality improvement monitoring within a managed behavioral health care system for the public consumer in the state of Michigan. A-21 1 Access Governance Quality Improvement Financial Viability Level of Functioning Collaboration NOTEs Italic text indicates under development for 1998 Michigan Mission Based Performance Indicator System - 1.0 Dimensions of Quality (8/22/96) PERFORMANCE INDICATORS ACCESS Penetration Rates of Under Served Populations Congruence of Potential Service Need with Persons Served Availability Timeliness Denial/Appeal Cost per Case EFFICIENCY Utilization of High Cost Services OUTCOME Satisfaction Consumer Satisfaction Community Satisfaction Complaint/Dispute Resolution Quality of Life Employment Consumer Perspective (Including Consumer Choice and Control) Adverse Consumer Outcomes Rates of Substantiated Rights Complaints Rates of Unexpected Deaths Recidivism PROVIDER REQUIREMENTS ACCESS Penetration Rates of Under Served Populations 1. % of persons served under the age of 18 / % of area census under the age of 18 2. % of persons served age 65 or older / % of area census 65 or older 3. % of persons served of ethnic minority groups / % of area census of ethnic minority groups Congruence of Potential Service Need with Persons Served 4. Persons Served Under the age of 18 meeting a definition of a Severe Emotional Disturbance (SED)/ Projected SED Need 5. Persons Served Age 18 or Older Meeting a definition of a Serious Mental Illness (SM1) Definition/Projected SMI Need Availability Provider Requirement FY 97 Indicators under construction for FY 98 Timeliness 6. Percentage of emergency referrals for Medicaid inpatient pre-admission screening completed within three hours or less 7. Average days between first request for non-emergent service to first non- emergent assessment by a professional 8. Average days between first non-emergent assessment with a professional to the start of a needed on-going service (Data to be reported separately for 5 sub- populations: Children with emotional disturbance, children with developmental disabilities, adults with developmental disabilities, adults with a mental illness under age 65, adults with a mental illness over the age of 65) 9. Average days between first request for non-emergent service to the start of a needed on-going service (Data to be reported separately for 5 sub-populations: Children with emotional disturbance, children with developmental disabilities, adults with developmental disabilities, adults with a mental illness under age 65, adults with a mental illness over the age of 65) Denial/Appeal 10. Percentage of second opinions requested under Sec. 705 of the Michigan Mental Health Code resulting in the delivery of service A-23 3 EFFICIENCY Cost per Case 11. Cost per case for adults with a severe and persistent mental illness as defined by DSM IV categories 12. Cost per case for adults with a mental illness not defined as severe and persistent by the DSM IV categories 13. Cost per case for children (age 17 or under) with a mental illness 14. Cost per case for persons with a developmental disability age 17 or under 15. Cost per case for persons with a developmental disability age 18 or over Utilization of high cost services 16. Days of inpatient care for adults with a mental illness per thousand population 17. Days of inpatient care for children with severe emotional disturbance per thousand population 18. Days of inpatient care for persons with developmental disabilities per thousand population A-24 4 Outcome Satisfaction - Consumer satisfaction 19. The percentage of adults with a mental illness who receive case management services who report satisfaction with services as reflected on the CSQ-8. 20. The percentage of children and/or their families who report satisfaction with services as reflected on the CSQ-8. 21. The percentage of persons with developmental disabilities who report satisfaction with services. A-25 Notes: CMHSPs will provide DCH with the necessary information to identify a statewide probability sample (e.g., a listing of CMHSP assigned id numbers). CMHSPs will then be asked to distribute the satisfaction measure to consumers. The responses will returned by the consumers directly to DCH who will arrange for the analysis and reporting of the data. CMHSPs continue to be required to assess local consumer satisfaction, and where appropriate, the satisfaction of collateral individuals, as part of their local quality improvement system. The Quality Improvement Council recommends as best practice the utilization of independent third parties to assist in the collection, analysis and reporting or consumer satisfaction. Independent parties might include administrative service organization contracts, local advocacy groups, local consumer groups, and local population specific advisory councils. Satisfaction - Community satisfaction - Under construction for 1998 Satisfaction - Complaint/Dispute Resolution 22. The number of substantiated recipient rights complaints per thousand persons served in the category of treatment suited to condition. 23. The number of substantiated recipient rights complaints per thousand persons served in the category of dignity and respect. 5 Quality of Life - Employment 24. The percentage of persons with developmental disabilities employed in integrated work settings (as defined by the federal Rehabilitation Act) 25. The percentage of persons in supported employment who are employed 10 or more hours per week 26. The percentage of persons in supported employment earning minimum wage or greater 27. The percentage of persons in supported employment continuously employed for the previous six months A-26 Note: Continuous employment includes breaks in employment of two weeks or less if the break was due to a planned job change with the same or new employer Quality of Life - Consumer Perspective Under construction for FY 98. Quality of life dimensions will be identified by consumers and will likely reflect multiple domains. Outcome - Adverse Consumer Outcomes 28. The number of unexpected client deaths (as defined under the full management contract) per thousand persons served 29. The number of substantiated recipient rights complaints per thousand persons served in all categories. 30. The percentage of persons for whom the CMHSP was responsible for pre-screening for inpatient care who are readmitted within 15 days for inpatient care to any psychiatric inpatient unit. The standard identified in the Medicaid Mental Health Clinic Services Manual is 15% or less. 6 Provider Requirements Level of Functioning A-27 Note: There were several purposes for selecting a uniform tool. They included: the state wide review of the relationships between levels of functioning and levels of care; possible case mix adjustments; the ability to determine the congruence of persons served with the Mental Health Code mandates for serving those with the most severe forms of disabilities; the potential utilization for local clinical outcome studies; and one !Possible !Piece of data to be considered in decisions for the future Medicaid Behavioral Health and Developmental Disabilities carve out plans. The tools required for use are: Child and Adolescent Functional Assessment Scale (All new non-emergent requests for service for children and adolescents ages 5 through 17) Inventory for Client and Agency Planning (All new non-emergent requests for service for persons with developmental disabilities and at the annual review date for ongoing cases) Behavior and Symptom Identification Scale (BASIS-32) '(All new non-emergent requests for service for adults with a mental illness and at the annual review date for ongoing cases) Folstein Mini-Mental State Examination (Supplemental to the BASIS-32 for persons with or suspicion of dementia) Notes: CMHSPs will be required to collect and report diagnostic, level of functioning, selected demographic and service utilization by social security number and Medicaid ID number for all persons entering service and those whose annual service date during the time frame 1/1/97 through 3/31/97, due to the department no later than 4/30/97. It is the intent of the department that CMHSPs will utilize multiple pieces of information when making decisions regarding the eligibility of consumers for service and/or the intensity of services provided. Level of functioning information which is only a partial reflection of need must be considered in combination with an individual's desires and the capacity of the support system around him/her. 7 A-28 ' Qua1 i ty Improvement 1. In addition to meeting the Mental Health Code and Administrative Rule requirements for Certification, CMHSPs must have an operational quality improvement system. 2. CMHSPs continue to be required to assess local consumer satisfaction, and where appropriate, the satisfaction of collateral individuals, as part of their local quality improvement system. 3. CMHSPs continue to be required to monitor the outcomes of service efforts to provide or assist in the provision of community living options for consumers as expressed by indicators of levels of independence in housing status. Instrument and techniques shall be chosen by each CMHSP. Collaboration 1. As required by Administrative Rule 330.2115 governing CMHSP certified children's diagnostic and treatment service, the program must have "written arrangements with public and private human service agencies which provide educational, judicial, child welfare, and other health services". One recommended strategy to achieve this requirement, at least in part, is through participation in a Multi-Purpose Collaborative Body. (9/11/96) 8 AGREEMENT REGARDING CMH BOARD POLICY ON REVIEW AND REPORTING OF DEATH Purpose: The purpose of this policy is to improve the quality of care of all consumers of CMH services. Policy: In an effort to ensure quality of care, the CMH board shall review and report all deaths of consumers: 1. who reside in 24 hour care and supervision settings (e.g. community residential facilities operated/contracted by the board including AIS homes, CLF homes, HCBW sites, AFC homes certified to offer specialized programs), and/or 2. whose functioning level is such that they receive the services of an interdisciplinary team, and/or 1. who was an active case known to the board and whose cause of death was suicide. Procedure: In implementing this policy, the board shall follow these procedures. A. The board shall have on file a copy of the procedures for notifying board administration of client deaths and for timely review of all deaths covered by this policy, including the personnel who shall participate in such reviews and the time frames for completing and reporting the findings to the appropriate parties. The board shall provide the Department with a copy of its local policy for reviewing and reporting death upon request. B. The board shall utilize the results of each review of death to examine the quality of care being provided through local programs and to make improvements whenever possible. C. The board shall complete a written review documenting a death which will include basic information on the consumer's name, gender, date of birth and date/time/place of death, as well as documentation regrading the following: 1. Client diagnoses, medical and psychiatric. 2. Cause of death. 3. Recent changes in medical or psychiatric status including notation on most recent hospitalization. 4. Summary of condition and treatment (programs and services being provided to client) preceding death. 5. Medications prescribed by CMH within last 30 days. 6. Any other relevant history. 7. Autopsy findings; the board shall ensure that an autopsy is requested unless the board has entered into the Death Report record a notation regarding why such request is inappropriate. 8. Any action taken as a result of the death review. The board shall provide a copy of the completed review of death including the information identified in 1-8 above to the Department when the death occurred within six months of the individual's discharge from a state operated service. For cases which re4uire more extensive review, the board will work with the Department to identify additional information which is necessary. The board shall, upon request, provide the Department with necessary detail on other specific deaths which occur, consistent with confidentiality provisions and rights protections as specified in the Michigan Mental Health Code and Administrative Rules. D. The board shall report to the Department on a semi- annual basis (every six months) an aggregate summary of deaths by population served, age, and cause of death (suicide, homicide, accident and natural causes) using the attached reporting form (Attachment A). Such information shall be used to access trends and for quality control across the public mental health system. A-30 BEHAVIOR MANAGEMENT COMMITTEE I. SUMMARY: Provides uniform guidelines for the establishment and operation of Behavior Management Committees. II. APPLICATION: A. Regional psychiatric facilities operated by the Department of Mental Health (DMH). B. Regional centers for developmental disabilities operated by DMH. C. Children's mental health hospitals operated by DMH. D. Special facilities operated by DMH. E. Community mental health (CMH) boards as specified in their master contract with DMH. F. Contractual providers of mental health services when adherence to this guideline is specifically required by such contract. III. POLICY: IT IS THE POLICY OF DMH THAT ALL PUBLICLY SUPPORTED MENTAL HEALTH AGENCIES SHALL HAVE A BEHAVIOR MANAGEMENT COMMITTEE, OR A COMMITTEE WHICH SUBSTANTIALLY INCORPORATES THE STANDARDS HEREIN DESCRIBED FOR A BEHAVIOR MANAGEMENT COMMITTEE, WHOSE APPOINTMENT, DUTIES, AND FUNCTIONS ARE PRESCRIBED BY THESE STANDARDS. IV. DEFINITIONS: APPLIED BEHAVIOR ANALYSIS: means the organized field of study which has, as its objective, the acquisition of knowledge about behavior using accepted principles of inquiry based on operant and respondent conditioning theory. It also refers to a set of techniques for modifying behavior toward socially meaningful ends based on these conceptions of behavior. Although this field of study is a recognized sub-specialty in the psychology discipline, not all practitioners are psychologists, and such training may be acquired in a variety of disciplines. DIRECTOR: means the director of the RMHA or his/her designee who may act on behalf of the RHMA. EMU: means responsible mental health authority, specifically a CMH service board, regional psychiatric, facility or regional center for developmentally disabled. BEHAVIOR MANAGEMENT: means the exercise of general control of behavior to achieve therapeutic objectives through the use of a variety of recognized techniques including shaping positive reinforcement and other techniques based on general behavior theory, verbal directions, physical guidance, physical management, medications, restraint and seclusion. BEHAVIOR MODIFICATION: means the systematic application of principles of general behavior theory to the development of adaptive and/or elimination of maladaptive behavior consistent with therapeutic objective. PROGRAM PLANS REQUIRING SPECIAL CONSENT: means any of the following: Aversive Techniques: Those techniques which require the deliberate infliction of painful stimulation (or stimuli which would be painful to the average person) to achieve their effectiveness. Examples of such techniques include electric shock, slapping, use of mouthwash or other noxious substance to consequate behavior or to accomplish a negative association with target behavior, and use of nausea- generating medication to establish a negative association with a target behavior or for directly consequating target behavior. Intrusive Techniques: Those techniques which impinge upon the bodily integrity or the personal space of the recipient to achieve therapeutic aims. Examples of such techniques include the use of a penile plethysmograph to monitor erectile response as part of a sexual reconditioning program, injections or medications when the target behavior is not due to an active psychotic process or where the medication approach is used to provide a reinforcing or punishing consequence due to its side effects as contrasted to its direct treatment effects, use of the "bell and pad" method of treating nocturnal enuresis, or the use of any direct observation procedures during times which would otherwise be considered private. Restrictive Techniques: Those techniques which, when implemented, will result in the limitation of the recipient's rights as specified in the Mental Health Code. Examples of such techniques include the systematic use of physical restraint or seclusion (both of which restrict freedom of movement), prohibiting communication with others to achieve therapeutic objectives, prohibiting ordinary access to meals or scheduled snacks, and any technique which can be described as an affront to the dignity of the recipient. Techniques which accomplish restriction, intrusion, or painful stimulation although called any other, name, and techniques which are insufficiently documented in the established literature related to behavior management. ("Insufficient" means, in the best judgment of the program author, there are too few references in a commonly available literature. A rough standard entails whether the technique is familiar to appropriately trained colleagues.) SPECIAL CONSENT: means obtaining the prior written approval of the recipient or the legal guardian specific to the use of a particular treatment approach which would otherwise entail violating the client's rights, even though general consent to treatment may have been obtained. V. STANDARDS: A. All agencies shall have a Behavior Management Committee comprised of at least three individuals, one of whom shall have both formal training and at least one year of experience in applied behavior analysis. Such training shall have been at the graduate level at an accredited college or university and shall have included course credits covering theory, application, and practicum experience. In addition, such persons shall attend professional development (continuing education) programs in behavior management. At least one of the aforementioned individuals shall be a full or limited licensed psychologist with the specified training and experience in applied behavior analysis; and at least one member shall be a licensed physician/psychiatrist or nurse who is not specifically required to have the behavior management background. When this behavior management expertise is not available at the agency, the responsible mental health agency (RMHA) shall notify DMH, requesting a temporary waiver and assistance in meeting this standard. B. The committee shall be appointed by the RMHA Director for a term of not more than two years. Members may be re-appointed to consecutive terms. C. The function of the Behavior Management Committee shall be to: 1. Review and approve (or disapprove), in light of current research and prevailing standards of practice, all behavioral programs utilizing aversive techniques, the generalized use of token economies, if the contingent removal of tokens is a planned part of the program, and those techniques requiring special consent by the recipient (see definitions above); such reviews shall be completed as expeditiously as possible; 2. Categorize behavioral management techniques approved by the RMHA into a hierarchy along the parameters of intrusiveness, aversiveness and restrictiveness. Using this hierarchy the committee shall determine he frequency of review necessary for program plans using approved behavior management techniques; 3. Review and approve all program plans which involve the use of psychoactive medications when they are A-34 applied for behavior control purposes and where the target behavior is not due to an active psychotic process; 4. Set a date specific to each approved program when it will re-examine the continuing need for the approved procedures. This review shall be at least annually; 5. Meet as often as needed and operate under chairpersonship appointed by the Director of the RMHA; 6. Keep all Behavior Management Committee meeting minutes, and clearly delineate the actions of the committee. 7. Provide decisions, in writing, to the responsible staff person with an indication of appropriate appeal process to the Director of RMHA in the event of a continuing dispute; 8. Abstain from decision making with respect to programs prepared by them or under their specific direction; In addition, the Committee may; 9. Advise and recommend to the Director of the RA, the need for specific training behavior modification for staff; 10. At its discretion, review all other behavior modification programs if such reviews are consistent with the agency's needs and approved in advance by the Director of the RMHA; 11. Advise the Director of the RMHA regarding administrative and other policies affecting behavior modification practices; 12. Provide specific case consultation as requested by professional staff of the RMHA; 13. Assist in assuring that related standards are met; and 14. Serve another service entity, i.e., small CMH board, if agreeable between the involved RMHA's. The RMHA may serve as a nonvoting member of the Behavior Management Committee. VI. REFERENCES : A. Ment al Public Act 258, of 1974. B. Standards for Intermediate Care Facilities _for the Mentally Retarded. C. Accreditation Council for Mental Retardation and Developmental Disabilities Standards. D. Standards of the Joint Commission on the Accreditation of Hospitals. E. Guidelines for the practice of behavior modification in community settings, by the Institute for the Study of Mental Retardation and Related Disabilities. VII. EXHIBITS: None Consumerism Guideline June 27, 1996 I. SUMMARY: This guideline sets policy and standards for consumer inclusion in the service delivery design and delivery process for all public mental health services. This guideline ensures the goals of a consumer-driven system which-gives consumers choices and decision-making roles. It is based on the active participation by primary consumers, family members and advocates in gathering consumer responses to meet these goals. This participation by consumers, family members and advocates is the basis of a provider's evaluation. Evaluation also includes how this information guides improvements. IS. APPLICATION: A. Psychiatric hospitals operated by the Department of Community Health (DCH). B. Centers for persons with developmental disabilities and community placement agencies operated by the Department of Community Health. C. Children's psychiatric hospitals operated by the Department of Community Health. D. Special facilities operated by the Department of Community Health. E. Community Mental Health Services Boards (CMHSB) under contract with DCH. F. All providers of mental health services who receive public funds, either directly or by contract, grant, third party payers, including managed care organizations or other reimbursements. POLICY: This policy supports services that advocate for and promote the needs, interests, and well-being of primary consumers. It is essential that consumers become partners in creating and evaluating these programs and services. Involvement in treatment planning is also essential. Services need to be consumer -driven and may also be consumer-run. This policy supports the broadest range of options and choices for consumers in services. It also supports consumer-run programs which empower consumers in decision-making of their own services. All consumers need opportunities and choices to reach their fullest potential and live independently. They also have the rights to be included and involved in all aspects of society. Accommodations shall be made available and tailored to the needs of consumers as specified by consumers for their full and active participation as required by this guideline. IV. DEFINITIONS: "Informed Choice" means that an individual receives information and understands his or her options. "Primary Consumer" means an individual who receives services from Department of Community Health or a community mental health service program. It also means a person who has received the equivalent mental health services from the private sector. "Consumerism" means active promotion of the interests, service needs, and rights of mental health consumers. "Consumer-Driven" means any program or service focused and directed by participation from consumers. "Consumer-Run" refers to any program or service operated and controlled exclusively by consumers. "Family Member" means a parent, stepparent, spouse, sibling, child, or grandparent of a primary consumer. It is also any individual upon whom a primary consumer depends for 50 percent or more of his or her financial support. "Minor" means an individual under the age of 18 years. "Family Centered Services" means services for families with minors which emphasize family needs and desires with goals and outcomes defined. Services are based on families' strengths and competencies with active participation in decision-making roles. "Person-Centered Planning" means the process for planning and supporting the individual receiving services. It builds upon the individual's capacity to engage in activities that promote community life. It honors the individual's preferences, choices, and abilities. "Person-First Language" refers to a person first before any description of disability. "Recovery" means the process of personal change in developing a life of purpose, hope, and contribution. The emphasis is on abilities and potentials. Recovery includes positive expectations for all consumers. Learning self- responsibility is a major element to recovery. V. STANDARDS: A-37% A. All services shall be designed to include ways to accomplish each of these standards. 1. "Person-First Language" shall be utilized in all publications, formal communications, and daily discussions. 2. Provide informed choice through information about available options. 3. Respond to an individual's ethnic and cultural diversities. This includes the availability of staff and services that reflect the ethnic and cultural makeup of the service area. Interpreters needed in communicating with non-English and limited-English-speaking persons shall be provided. 4. Promote the efforts and achievements of consumers through special recognition of consumers. 5. Through customer satisfaction surveys and other appropriate consumer related methods, gather ideas and responses from consumers concerning their experiences with services. 6. Involve consumers and family members in evaluating the quality and effectiveness of service. Administrative mechanisms used to establish service must also be evaluated. The evaluation is based upon what is important to consumers, as reported in customer satisfaction surveys. 7. Advance the employment of consumers within the mental health system and in the community at all levels of positions, including mental health service provision roles. B. Services, programs, and contracts concerning persons with mental illness and related disorders shall actively strive to accomplish these goals. 1. Provide information to reduce the stigma of mental illness that exists within communities, service agencies, and among consumers. 2. Create environments for all consumers in which the process of "recovery" can occur. This is shown by an expressed awareness of recovery by consumers and staff. 3. Provide basic information about mental illness, recovery, and wellness to consumers and the public. C. Services, programs, and contracts concerning persons with developmental disabilities shall be based upon these elements. 1. Provide personal preferences and meaningful choices with consumers in control over the choice of services and supports. 2. Through educational strategies: promote inclusion, both personal and in the community; strive to relieve disabling circumstances; 1ctively work to prevent occurrence of increased disability; and promote individuals in exercising their abilities to their highest potentials. 3. Provide roles for consumers to make decisions in polices, programs, and services that affect their lives including person-centered planning processes. D. Services, programs, and contracts concerning minors and their families shall be based upon these elements: 1. Services shall be delivered in a family-centered approach, implementing comprehensive services that address the needs of the minor and his/her family. 2. Services shall be individualized and respectful of the minor and family's choice of services and supports. 3. Roles for families to make decisions in policies, programs and services that affect their lives and their minor's life. E. Consumer-run programs shall receive the same consideration as all other providers of mental health services. This includes these considerations: 1. Clear contract performance standards. 2. Fiscal resources to meet performance expectations. 3. A contract liaison person to address the concerns of either party. 4. Inclusion in provider coordination meetings and planning processes. 5. Access to information and supports to ensure sound business decisions. F. Current and former consumers, family members, and advocates must be invited to participate in implementing this guideline. Provider organizations must develop collaborative approaches for ensuring continued participation. Organizations' compliance with this guideline shall be locally evaluated. Foremost, this must involve consumers, family members, and advocates. Providers, professionals, and administrators must be also included. The CMH board shall provide technical VI. assistance. Evaluation methods shall provide constructive feedback about improving the use of this guideline. This guideline requires that it be part of the organizations' Continuous Quality Improvement. AND LEGAL .AUTHUB Act 258, Section 116(e), Public Acts of 1974 as amended, being MCL 330.1116, 1704, 1708. RED PERSONAL CARE IN NON-SPECIALIZED RESIDENTIAL SETTINGS This guideline rescinds and replaces guideline 01-C-1116 ( j )/GL-00, dated July 18, 1984; Personal Care in Non-Specialized Residential Settings . I. SUMMARY This guideline establishes operational policy; program and clinical documentation requirements for issuing payments through the Model Payment System (MPS) for mental health recipients who need personal care services when placed in a non-specialized residential foster care setting. II. APPLICATION A. Community Mental Health Services Programs (CMHSP) and their contract agencies who provide case management services to recipients in non-specialized residential foster care settings; and, as specified in the master contract with the Department of Community Health (DCH). B. Psychiatric Hospitals and Centers operated by, or under contract with the Department of Community Health. C. Special facilities operated by the Department of Community Health. D. Children's units operated by the Department of Community Health. III. POLICY Assure that the need for personal care services is assessed, ordered and covered prior to placement of a mental health recipient into a non-specialized residential foster care setting to meet Medicaid standards and receive payment for personal care services from MPS. IV. DEFINITIONS CLIENT SERVICES MANAGEMENT: a related set of activities which link the recipient to the public mental health system and which coordinate services to achieve a successful outcome. IV. DEFINITIONS (Cont.) FAMILY MEMBER: means a parent or step-parent of a minor child or a spouse. INDIVIDUAL PLAN OF SERVICE (IPS): a person centered planning process to develop a written plan which identifies mental health services as defined in Section 712, Act 290 of the Public Acts of 1995. MEDICAID (MA) DESIGNATED CASE MANAGER: case manager must be either a qualified mental retardation professional (QMRP) as defined in 42 CFR 483.430, or a qualified mental health professional (QMHP) as defined in Michigan's Medicaid Mental Health Clinic Provider Manual, Chapter III. NON-SPECIALIZED RESIDENTIAL FOSTER CARE SETTING: a licensed dependent living arrangement providing room, board and supervision, but not providing in-home mental health services. PERSONAL CARE SERVICES: services provided in accordance with an individualized plan of service that assist a recipient by hands-on assistance, guiding, directing, or prompting of ADLs in at least one of the following activities: A. EATING/FEEDING: the process of getting food by any means from the receptacle (plate, cup, glass) into the body. This item describes the process of eating after food is placed in front of an individual. B. TOILETING: the process of getting to and from the toilet room for elimination of feces and urine, transferring on and off the toilet, cleansing self after elimination, and adjusting clothes. A commode in any location may be considered the "toilet room" only if in addition to meeting the criteria for' toileting" the individual empties, cleanses and replaces receptacle without assistance from another person(s). C. BATHING: the process of washing the body or body parts, including getting to or obtaining the bathing water and/or equipment, whether this is in bed, shower or tub. IV. DEFINMONS (Cont.) D. GROOMING: the activities associated with maintaining personal hygiene and keeping one's appearance neat, including care of teeth, hair, nails, skin, etc. E. DRESSING: the process of putting on, fastening and taking off all items of clothing, braces and artificial limbs that are worn daily by the individual, including obtaining and replacing the items from their storage area in the immediate environment. Clothing refers to the clothing usually worn daily by the individual. Individuals who wear pajamas or gowns with robe and slippers as their usual attire are considered dressed. F. TRANSFERRING: the process of moving horizontally and/or vertically between the bed, chair, wheelchair and/or stretcher. G. AMBULATION: the process of moving about on foot or by means of a device with wheels. H. ASSISTANCE WITH SELF-ADMINISTERED MEDICATION: the process of assisting the client with medications that are ordinarily self administered, when ordered by the client's physician. V. STANDARDS A. Recipient must be Medicaid active during effective dates of service. B. Providers of non-specialized residential services must be licensed and meet minimum requirements of the Department of Consumer and Industry Services (DCIS) and DCH as defined and contained therein, Act 117, Public Acts of 1973, as amended and Act 218, Public Acts of 1979, as amended, for non-specialized residential settings such as: homes for the aged, adult foster care family home, adult foster care small group home, adult foster care large group home, adult foster care congregate facility, foster family home, foster family group home, and child caring institutions. IV. STANDARDS (Cont.) C. Personal care services are covered when ordered by a physician or a Medicaid (MA) designated case manager based upon face to face contact with recipient, and in accordance with an Individual Plan of Care (IPS) and/or a person who is not a member of the individual family. D. Supervision of personal care services is required and may be provided by a registered nurse, physician assistant, a MA designated case manager supervisor or a MA designated case manager other than the case manager who ordered services. E. Provider of service must maintain a service log that documents specific days on which personal care services were delivered consistent with the recipient's individual plan of services. F. Supervision of personal care services is a two-part process which includes: (1) Approval of covered personal care services which occurs after a Medicaid designated case manager or physician has ordered personal care services which must be written in the IPS or on a program approved form. (2) A reevaluation or review of recipient personal care needs which must occur within a calendar year of the last plan for personal care services or last re-evaluation or review, whichever occurred last, based upon either a face-to-face contact with recipient or an administrative review of plan of service. A Medicaid designated case manager shall initiate a re-evaluation or review on a program approved form, which must be signed by either a registered nurse (RN), physician assistant, a MA designated case manager supervisor or a MA designated case manager other than the case manager who ordered services. G. Use DCH's - Personal Care/Model Payments Manual (current) for detailed operational practices, program policies and instructions. VI. REFERENCES AND LEGAL AUTHORITY A. Social Security Act, Section 1905(a) (17). B. 42 CFR 440.170 and 42 CFR 483.430. • C. Act 258 of The Public Acts of 1974 (MCLA - 330.1116) and Act 290 of The Public Acts of 1995 (MCLA - 330.1712). D. Michigan's Medicaid State provisions for Title XIX of the Social Security Act. E. Michigan Department of Social Services/Family Independence Agency, Service Manual, Adult and Family Services Item - 314 and 372, Home Help Adult, Community Placement and Personal Care Services, Adults Foster Care (AFC) and Homes for the Aged (HA), Personal Care/ Supplemental Payments. VIII. EXHIBITS NONE. n Uniform Audit Requirements - Community Residential Service Contracts Audit Criteria and Audit Audit Audit Professional Audit Scope Reauirement Purpose Objective Standards Frequency , ----, . Witt Cost: t t:ontracts with a single contractor with total annual A B D E F H 1 budgets equal to or exceeding $750,000 Contracts with a single contractor with total annual A B D E F H J budgets less than $750,000 Fee for Service: • Contracts with a single contractor with total annual A C D E G H I per diem payments equal to or exceeding $750,000 . ._ . Contracts with a single contractor with total annual per diem payments less A C D E G H J than $750,000 ._ • Fee for service contracts with total annual payments of less than $50,000 (state and Medicaid) would not be subject to these uniform audit requirements. These contracts may be subject to these audit requirements at the discretion of DMH or CMH. Audit Type A - Audit is defined as a financial audit. - The result of this audit would be the issuance of an audit report that would be based upon the provisions of SAS 62, 'Special Audit Reports.' The following segments of the standard should be applied: 1. Paragraph 15, for an engagement to express an opinion on specified elements of a schedule of revenue and expenditures as required by contract stipulation. 2. Paragraph 19, in which compliance with terms of the contract, regarding accounting matters, is addressed. A negative assurance regarding compliance should be included. It should be noted the compliance with financial terms of the contract should be examined during the course of the audit. Criteria and Requirements B - Financial provisions of the contract with the residential care provider (contractor). - For CMH, financial policies and procedures contained in the DMH/CMH contract. - The audit is to determine whether the costs reported to the Department of Mental Health (DMH) or the community mental health board (CMH) are fairly presented in accordance with the terms of the home contract and, for CMH, the applicable policies and procedures contained in the DMH/CMH contract. C - Financial provisions of the contract with the residential care provider (contractor). - For CMH, financial policies and procedures contained in the DMH/CMH contract. - The audit is to determine whether the home costs are fairly presented in accordance with the terms of the home contract and, for CMH, the applicable policies and procedures contained in the DMH/CMH contract. Audit Scope D - To obtain an understand of the internal control structure sufficient to plan the audit and to determine the nature, timing, and extent of substantive audit procedures necessary to determine that the schedule of revenue and expenditures is fairly , presented in accordance with provisions of the applicable cbntract. Also, the auditor shall prepare a schedule of audit adjustments required to adjust the schedule of revenue and expenditures to be in compliance with the terms of the applicable contract. Audit Purpose E - To determine that costs are reported in accordance with the financial terms of the home contract and, for CMH, the applicable DMH/CMH contract terms. Audit Objective F - To determine that the schedule of revenue and expenditures is fairly presented in accordance with the home contract terms and the applicable DMH/CMH contract terms. - To prepare a schedule of audit adjustments. G - To determine that the schedule of revenue and expenditures is fairly presented, are appropriately classified in accordance with the home contract terms and, for CMH, the applicable DMH/CMH contract terms. --- To prepare a schedule of audit adjustments. - Professional Standards H - This audit will be conducted in accordance with generally accepted auditing standards (GAAS). Audit Frequency I - To be performed on an annual basis. Audits may be performed more frequently due to special circumstances (change of contractors, federal or county requirements, etc.) J - To be performed, at a minimum, once every three years with the option of these audits covering all fiscal years since the last audit. Audits may be performed more frequently due to special circumstances (change of contractors, federal or county requirements, etc.) \ ATTACHMENT B Page 1 MONITORING INFORMATION REQUIREMENTS This Attachment identifies summary reporting requirements and contains copies of required reports, as follows: I. Reporting requirements from minimum data set covering activity, client demographics and gross cost of services: a. A semi-annual aggregate report (format attched on page submitted on diskette, DCH Sub-Element/Cost Report.) b. A Year-end aggregate report, as described above. c. At year-end, a data file which aggregates minimum data set activity and client demographic information to an 'individual record for each client .served during the fiscal year. This data file will contain a record for each consumer, utilizing Social Security number as the unique consumer identifier. d. At year-end, a data file which identifies gross cost for each sub-element for which activity is required. II. Performance Indicator System Reports (attached) -- Reporting dates, report formats and instructions are included as pages 3 through 16 of this Attachment B. III. Death Report IV. Managed Care Monitoring Reports (Attached) Other DD Population Attachment B Page 2 I. CMH Sub-Element/Cost Report FY 1996-97 CMHSP: Oct.-Mar. Completed By: Oct.-Sept. _ MI-C Population Due April 30 Due December 31 MI-A Population . . Program Element/ Cases Units Total Costs Cases Units Total Costs Cases Units Total Costs Total Costs Sub-Elements Inpatient Bd Managed Local lnpt Bd Managed State 'not :. Residential Bd Managed Residential • St or Other -Bd Mg Res Bd Managed -Crisis Res. Supported Independence Day Program Partial Hasp Psychosocial Rehab Ctr Other Day Programs: • Outpatient ? Clinic Services Emergency Services Supportive Service Assertive Comm Trtmt Crisis Stabilization Team . Comm Treatment Team -.0 .. Client Services Mgmt Family Supp/Hm Based Integrated Emp Serv . Comm Integration Serv Respite Res Services . _ Prevention -.,. . . Direct Service Models ...„.5;4-..1? - Other Service Models iii,..1 '• . ... 4 #.: ..,,, :.''' .•::":: AV... "Or?' .'' . - t -ftlt 7:1. ‘,- • ' . 4. 1,44 le•- ...:.. Board Administration ..... . , •••.: 0 ,.. art:•:, -4:::...i.. ; .. : ....„-!... .,.....p Population Total 511:z ..,.. a >,... ,.. . _ ... ...q.......," Attachment B Page 3 Michigan Mission Based Performance Indicator System - 1.0 A. Access: Penetration Rates Due: 7/31/97 B. Access: Timeliness(Inpatient Screening) Due: 4/30/97 12/31/97 C. Access: Timeliness Due: 4/30/97 7/31/97 D. Access: Denial/Appeal Due: 4/30/97 7/31/97 E. Recipient Rights Complaints Due: 4/30/97 7/31/97 F. Inpatient Recidivism Due: 12/31/97 G. Level of Functioning Data 1. Due: 4/30/97 2. Data to be submitted electronically will include client records which include the following information: social security number, Medicaid number, demographic and service utilization data as required by the minimum data set and level of functioning data. The level of functioning data would include: Child and Adolescent Functional Assessment Scale Required administration: All new requests for service for children and ' adolescents ages 5 through 17. Required reporting to DCH: 8 child functioning subscales (Role Performance - School/work; Role Performance - Home,;Role Performance - Community; Behavior toward others, Moods/emotions; Self-Harmful behavior; Substance Use; Thinking) 2 care giver subscales (Using a clinician perceived composite of the care givers) (Material Needs; Family/social support) Attachment B Page 4 Behavior and Symptom Identification Scale Required administration: 1. All new non-emergent requests for service for adults with a mental illness 2. At the annual review date for ongoing cases Required reporting to DCH: 5 functioning subscales. from the BASIS-32 (Relation to self and others, daily living and role functioning, depression and anxiety, impulsive and addictive behavior, and psychosis) Inventory for Client and Agency Planning: Required administration: 1. All new non-emergent requests for service for persons with developmental disabilities 2. At the annual review date for ongoing cases Required reporting to DCH: 7 functioning subscales (Adaptive Behavior: Motor skills, Social & communication skills, Personal living skills, Community living skills; Ma!adaptive Behavior: Self injury/stereotyped/withdrawn, Offensive/uncooperative, Disruptive/destructive/hurts others) Folstein Mini-Mental State Examination:(This would be supplemental to the BASIS-32 for persons suspected of having dementia.) Required administration: 1. All new non-emergent requests for service for persons with or suspicion of dementia 2. At the annual review date for ongoing cases Required reporting to DCH: Single score H. All other data for the computation of performance indicators will be derived from other data reporting requirements contained elsewhere in this contract (e.g., the calculation of cost per case for specific diagnostic and age subgroups will be calculated from the minimum data set information submitted electronically by the CMHSPs.) Persons Served 1990 Census Attachment B Page 5 ACCESS: PENETRATION RATES (1-5) CMHSP NAME: Time Period: 411/97 - 6130197 . ,..J Persons Aged <18 r.-...` - A ..4 , rpti 4,12S Persons Aged 65+ 1. , •••k• 41. v . , Persons of Ethnic Minorities •- , . Persons Aged 18+ with SMI . ,-- . , . Persons Aged <18 -..,‘,, -' ., with SED - .. .. . -- • - Definitions: 1. Persons aged 18+ with a Serious Mental Illness are those persons with the following diagnostic categories: Schizophrenia and other Psychotic Disorders (295.xx; 297.1; 297.3; 298.8; 298.9) Mood Disorders or Major Depressions and Bipolar Disorders (296.xx) Dementia (290.xx) Panic Disorder, Phobias and Obsessive Compulsive Disorder (300.xx) Somatization Disorder (300.81) Antisocial Personality Disorder (301.7) Attachment B Page 6 ACCESS: PENETRATION RATES (1-5) Definitions Page 2 2. Definition of Children with a Serious Emotional Disturbance -- Pursuant to Section 1912 © of the Public Service Act, as amended by Public Law 102-321 "children with a serious emotional disturbance" are persons: From birth up to age 18, The definition of serious emotional disturbance in children is restricted to persons up to age 18. Who currently or at any time during the past year, The reference year in each of the definitions refers to a continuous 12-month period because this is a frequently used interval in epidemiological research and because it relates closely to commonly used planning cycles. Have had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria specified within DSM-IV, American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, or DSM-IV. These disorders include any mental disorder (including those of biological etiology) listed in DSM-IV or their ICD-9-CM equivalent (and subsequent revisions), with the exception of DSM-III-R `V" codes, substance use, and developmental disorders, which are excluded, unless they co-occur with another diagnosable serious emotional disturbance. All of these disorders have episodic, recurrent, or persistent features; however, they vary in terms of severity and disabling effects. That resulted in functional impairment which substantially interferes with or limits the child's role or functioning in family, school, or community activities. Functional impairment is defined as difficulties that substantially interferes with or limit a child or adolescent from achieving or maintaining one or more developmentally-appropriate social, behavioral, cognitive, communicative, or adaptive skills. Functional impairments of episodic, recurrent, and continuous duration are included unless they are temporary and expected responses to stressful events in the environment. Children who would have met functional impairment criteria during the reference year without the benefit of treatment or other support services are included in this definition. At tachment B Page 7 ACCESS - TIMELINESS/INPATIENT SCREENING (6) CMHSP NAME: Time Periods: 10/1/96 - 3/31/97 4/1/97 - 9/30/97 -:•;.r..!,':.-:?. - ,..,.., Numberof Emergency . ersent lot ' :Numb4.i., , . „-l'e—,rn„ : .7 '1 Ord lifetrrkmpk4 Wed!Within ...npàtlent.Screenlng Durliig Thelie'l.,..i.; our'i %b- rt.e.,.t,s A ,. ..,..., :g,.h—ie-Stan4,.dll .2. .,. d ...- , - , Attachment B Page 8 ACCESS: TIMELINESS (7,8,9) CMHSP NAME: Time Periods: 1/1/97 - 3/31/97 411/97 - 6/30/97 1 Persons .Ayg.:#,Days, 41:Persons AverageNumber of .Days ' . 1Fleceivingan . :..,''lletSfeek;..:. ' I . ., •• - • • „,,,,,4-:• ,,,,i; A: .f: . 11illitial .,-... . .. -- . _ . '-,itiOn*nersient:,..,,,.:, .- ....., . :.-PnifeisiOnet.',1,it,4 men .. , :: • ,j x . . !;1;' A - , MIC MIA <65 MIA 65+ . DD <18 DD 18+ TOTAL Definitions: 1. Days are calendar days. 2. First request is a request by the individual, family, legal guardian, or referral source which results in the scheduling of a face to face assessment with a professional. 3. Non-emergent assessment and services excludes pre-admission screening for and receipt of psychiatric in -patient care. 4. Non-emergent assessment by a professional must be done face to face for the purpose of determining appropriateness for ongoing service. Average days between request and assessment should not include no show or cancellation dates. 5. Ongoing service includes any recommended service, including case management, respite care, etc. It excludes supplemental assessment services Attachment B Page 9 ACCESS: DENIAL/APPEAL (io) CMHSP NAME: Time Periods: 10/1/96 - 3/31/97 4/1197 - 6/30/97 Total # Persons Total # Persons Total # Persons Yofil- Jrlierionii , . . . . . . . , Receiving an initial ,.. Assessed but , Requesting _ ...Receiving Service ; 1441i4hiegen!''''' ''''No t' Authorlia- . -Seàond Opinion'. OlIO"-- a' '''' • " -.ProfeaSional ' ' Any Service - -1.1 ' 't • 'oritrOpinio -:Ass- ess. [tient- , _ , . , -.. NOTE: 1. Section 330.1705 of Public Act 258 of 1974 as revised, was intended to capture requests for initial entry into the CMHSP. Requests for changes in the levels of care received are governed by other sections of the Code. Attachment B Page 10 Definitions: Persons receiving supported employment: Persons who have accessed supported employment services (individual job coach, enclave, mobile crews, and/or transitional employment) for whom the CMHSP expects to provide ongoing, long term supports which would generally include two contacts per month with mental health staff which assist in an individual maintaining employment. Continuous Employment Continuous employment includes breaks in employment for two weeks or less if the break was due to a planned job change with the same or new employer. Integrated Work Setting Integrated work setting means job sites where either- (1)(1) Most employees are not disabled; and (ii) an individual with the most severe disabilities interacts on a regular basis, in the performance of job duties with employees who are not disabled; and (iii) if an individual with the most severe disabilities are part of a distinct work group of only individuals with disabilities, the work group should consist of no more than 8 individuals; or (2)if there are no other employees or the only other employees are individuals who are part of a work group... the individual with the most severe disabilities interacts on a regular basis, in the performance of job duties, with individuals who are not disabled, including members of the general public." (February 18, 1994 Federal Register) Enclave Consists of a small group (8 or less) of individuals with disabilities working within a business or factory. Supervision and training may be combined or separate positions. Preferably supervision and training would be provided by the employer but may be provided by the service provider agency. Mobile Crew Consists of a small group (8 or less) of individuals who move from site to site to perform work. The crew has their own equipment. Job training and supervision are usually the responsibility of the service provider agency. Attachment B Page 11 Transitional Employment A model of supported employment specific to persons with mental illness. It involves multiple part-time work placements with community-based employers, paid by the employer. Support services are provided by a psychosocial club house program prior to and concurrent with the transitional employment experiences. Long term support would be available through the psychosocial club house for subsequent full-time placements. 2 SUPPORTED EMPLOYMENT REPORT Participants on: March 31 June 30 CLIENT POPULATION : Persons with Developmental Disabilities BOARD Attachment B Page 12 INDIVIDUAL PLACEMENTS - Total Number of Number Number Number Number Individual of Minimum Employed with Placements: Persons Wage or 6 Months Employer Above Medical Benefits 30 or More Hours 20-29 Hours 10-19 Hours Less than 10 Hours . ENCLAVES Number Number Number Number with Number of of Minimum Working Employer Enclaves: Persons Wage or 6 Months Medical Benefits Above , 30 or More Hours 20-29 Hours 10-19 Hours Less than 10 Hours MOBILE CREWS Number Number Number Number with Number of of Minimum Working Employer Mobile Crews: Persons Wage 6 Months Medical Benefits or Above 30 or More Hours , 20-39 Hours 10-19 Hours Less than 10 Hours DAY PROGRAM Number of Persons in Day Activity programs: Number of Persons in Work Activity programs: Number of Persons in 'Type C" Day programs: Notes: 1) Persons who participated in both supported employment and day program on the date of data collection should be included in the supported employment category only. 2) Persons who particiapted in more than one type of day program on the date of the data collection should be counted only once. Attachment B Page 13 BOARD CUENT POPULATION : Persons with Mental Illness SUPPORTED EMPLOYMENT REPORT Participants on: March 31 June 30 INDIVIDUAL PLACEMENTS Total Number of Number Number Number Number Individual of Minimum Employed with Placements: Persons Wage or 6 Months Employer Above Medical — Benefits 30 or More Hours . 20-29 Hours 10-19 Hours . Less than 10 Hours . , ENCLAVES Number Number Number Number with Number of of Minimum Working Employer Enclaves: Persons Wage or 6 Months Medical Benefits --- Above 30 or More Hours 20-29 Hours 10-19 Hours Less than 10 Hours MOBILE CREWS Number Number Number Number with Number of of Minimum Working Employer Mobile Crews: Persons Wage 6 Months Medical Benefits or Above 30 or More Hours 20-39 Hours 10-19 Hours Less than 10 Hours TRANSMONAL EMPLOYMENT Number of Persons in Number Number Number Number with Transitional of Minimum Working Employer Employment: _____ Persons Wage or 6 Months Medical Benefits _ Above 30 or More Hours 20-29 Hours 10-19 Hours Less than 10 Hours . CONSUMER RUN BUSINESSES Number of persons employed in consumer owned and run businesses, including Fairweather Lodge Businesses: 4Person.s Discharged From . Psychiatric Inpatient Care itPersons Discharged an Readmitted Within 15:Days To Another inpatient Unit Percent(%) of Persons Readmitted Within 45 Da At tachment B Page 14 OUTCOME: INPATIENT RECIDIVISM (30) CMHSP NAME: Time Periods: 1/1/97 - 3/31/97 4/1/97 -9/30/97 NOTES: 1. The number of persons screened and admitted includes admisions to All Psychiatric Hospital. It is Not limited to persons who are Medicaid eligible only. 2. This data is intended to capture Admissions and Readmissions, Not Transfers to another psychiatric hospital. Attachment B Page 15 RECIPIENT RIGHTS COMPLAINTS (n,23,29) CMHSP NAME: Time Periods: 1/1/97 - 3/31/97 4/1/97 - 6/30/97 , COMPLAINT TOTAL , .. ., . .. .. ,.. CATEGORY COMPLAINTS FILED BSTANTJANTED • ..... -- — i' ''''' r° 1,-,1. tompfAwrisnixt, ‘„ Dignity and Respect Treatment Suited to Condition TOTAL of ALL Recipient Rights Complaints Regardless of Category Attachment B Page 16 III. Semi-Annual Aggregated Report of Death Community Mental Health Board: Report Date:_ Population: MI # Deaths This Period # Deaths Year to Date AGE I AGE Cause of 18& 19-35 36-60 61+ 18& 19-35 36-60 61+ TOTAL Death Under Under Suicide Homicide ACCIDENT — (Please enter data in the appropriate box below.) While Under Program 1 Supervision Not Under Program Supervision "Natural Causes" TOTAL 1 COMMENTS: Instructions: If a board has recorded deaths in BOTH POPULATIONS, TWO reports will be required - ONE for persons with MI and ONE for persons with DD. Boards may utilize another format, provided all information is included. "Natural Causes" refers to deaths occurring as a result of a disease process in which death is one anticipated outcome. Reports are due on APRIL 30 for the period October 1 through March 31 and on DECEMBER 31 for the period April 1 through September 30. Use EITHER the YEAR TO DATE or the THIS PERIOD columns for the April 30 report. DD BOARD: Managed Care Monitoring Reports 'V Do rt (13 CD .7 !rJ 3 ft) :3 :73 REPORTING PERIOD APPLICATION OF CLINICAL CRITERIA Inpatient Reviews PHP Reviews Of Number Of Number Conducted, Of Number Percent (%) of Conducted, Of Number Percent (%) of Number of Monitored- • Cases Number of PAP Monitored- Cases Total Number of Reviews Evaluated, Monitored- Total Number of Reviews Evaluated, Monitored- Inpatient Monitored- Number That Evaluated That PHP Reviews Monitored- Number That Evaluated That Reviews Evaluated Were Handled Were Handled Conducted Evaluated Were Handled Were Handled Conducted This Through According to According To During This Through According to According To Report Period Internal QI Published UM Published UM Report Period Internal QI Published UM Published UM (Count) Process (Count) Criteria (Count) _ Criteria (Count) Process (Count) Criteria (Count) Criteria COORDINATION OF CARE WITH PRIMARY PHYSICIAN OR RESPONSIBLE HEALTH CARE PLAN Screening and Reviews Significant Changes Of Cases Monitored- Evaluated and Which had a Of Cases Primary Care Percent (%) of Number of Monitored- Physician or Cases Cases Evaluated in Of Number of Responsible Monitored- Monitored- Which there had Of Total Cases Health Plan, the Evaluated in Evaluated been Significant Number of Monitored- Number in Which There Through Of Cases Changes, the Cases, the Evalualsed„ the Which There was Timely Internal QI Monitored- Number in Percent (%) of Total Number of Number That Number Who was Timely Notice (Within Processes for Evaluated, the Which There Cases Cases Screened Were had an Notice to Standards) to Timely Number of was Timely Monitored- - Reviewed for Monitored- Identified Primary Care Physician or Notification to Cases in Which Notice to Evaluated in Inpatient or PI IP Evaluated Primary Care Provider - Responsible Physician/Healt There had been Physician or Which Notice to Care During Through Physician or Responsible Health Plan of h Plan of Significant Health Plan of Physician of Report Period Internal QI Responsible Health Plan of Case Changes Changes Changes Changes Met (Count) Process (Count) Health Plan Disposition Disposition (Count) (Count) (Count) Standard 1-4 QIPMP DIMENSION H: ATTRIBUTES OF CARE MMC I BOARD: REPORTING PERIOD A RELAPSE/RECIDIVISM RATES - DETAIL ANALYSIS - Of Number Of Number Discharged, Reviewed, Of Number Number Number of Number of Reviewed, Readmitted These Readmits Number of Within 15 Total Days of Readmits Deemed Readmits • Days of Readmission Reviewed Warranted (i.e. Deemed Discharge to a Recidivism Care Attributed Through CM11 not due to Unnecessary Number of General Rate (B to Hospital of Clinical premature 1Iad First Care Discharges Hospital Divided by A Discharge Staffing or discharge, poor Episode Been During Report Psychiatric Expressed as During this internal QI discharge Better Handled Ilospital (of Discharge) Name Period Unit %) Report Period Process planning, etc.) or Managed _ _ . - ' - TOTALS - _ DI ("+ c+ CD 0.0 co a r+ CO Q1PMP DIMENSION II: ATTRIBUTES OF CARE MMC 2 BOARD: Recipient's Name Date of Last Continuing Stay Review Date of Next Scheduled Continuing Stay Review 9 1.uaultioeli.v Oi tO REPORTING PERIOD Out-of-State Children's Psychiatric Inpatient Placement Activity Out-of-State Inpatient Facility Name Date of Admission 1 QIPMP DIMENSION V: SERVICE UTILIZATION MMC 3 BOARD: REPORTING PERIOD _ .P .. t k Total Number of C L. Staff Authorized to Conduct These .5. Activities Reviews a et. inpatient Pre-Screening inpatient Continuing Stay Reviews PHP Pre-Screening PHP Continuing Stay Reviews Reconsiderations -17 Cts r+ U:1 rt- fb 111 IN I CO S. .. CMH BOARD CREDENTIALING AND PRIVILEGING PROGRAM FOR MEDICAID MANAGED MENTAL HEALTH CARE Number Authorized B Number By Discipline OIPMP DIMENSION II: ATTRIBUTES OF CARE MMC 4 BOARD: itt.:rUirt. a al Ito eidAit.si.; CMH INFORMAL CONSUMER RECONSIDERATION ACTIVITY RELATED TO MEDICAID MANAGED CARE • Number of Consumer Number of Consumer Total Number of Reconsideration Reconsideration Number of Grievances or Requests or Grievances Requests or Grievances Administrative Objections or Regarding CMH Regarding CMH PUP Complaints Lodged Complaints handled Inpatient Decisions Decisions Handled Relating to CMH Through CMH Internal Handled Through CMH Through CMH Clinical Execution of Medicaid Dispute Resolution Clinical Review System Review System During Managed Care Duties System This Report During Report Period Report Period During Report Period Period , 'CI A DP el' 113 c+ (DO' a ID rP CO QIPMP DIMENSION III: APPEALS AND RECONSIDERATIONS MMC 5 REPORTING PERIOD 9 luaul3R414 "CI DI UZI (1) PROVIDER REQUEST FOR RECONSIDERATION OF CMH SCREENING DECISIONS Appealing Patty: Primary Care Physician or Responsible Health Plan Treating Psychiatrist Hospital/Facility Other TOTALS: - Number of Number of Number of Number of Number of Requests Number of Number of Number of Requests Number of Number of Number of Requests CM" CMII Percent (A) Number of Request, CAM CM Percent (4) for Reconsideration Cbili CIAll Percent C4/ for Reconsideration CMH CMII Percent f%) for Reconsideradon Dechl°^1 Ded.kim of °will". for Reconsideration Decisions De""d of D"IsW" of Partial Decons Decisions of Decisions of Partial Decisions Decisions of Daimons Changed Upheld Changed Changed Upheld Changed .. . Changed Upheld Changed .. . .. Changed Upheld Changed of Inpatient of Inpatient siospitarkation isospotausation Upon Upon Upon Upon 1/Pon Upon Upon (Von Upon Upon Upon Upon Pre-Screening Reconsider- Reconsider- Reconsider. Continuing Stay Itecon ider. Reemeld.. pecomider. pre-Screening Reconsider- Reconsider- Reconsider- Continued St27 Recontlder. R000rtolder- Reconsider- Decisions slim &don . 'don Decisions atiOn uion , allots Decisions 'don alien stion Decisions ellen Mien Won . - • QIPMP DIMENSION III: APPEALS AND RECONSIDERATIONS MMC 6 DURK-IA ittkutu rtRIOD • Provider/Referral Source Number Surveyed: Number Responding: Survey Period: Number of Respondents Giving This Response a 2UaUll13e231i 1. a) Stree0y Agree 6 5 Agree 4 3 Sires* Meagre. 2 CMH responded promptly to requests to referrals and service requests. CMH staff provided timely feedback regarding disposition of referrals or service contacts. CMH helped referred individuals get the right type of services for their problems CMH staff were knowledgeable and competent. Communication with CMH on mutual clients was satisfactory. In general, I was satisfied with the service provided by CMH. 11111 1 111 1 11111 11111 11111 Q1PMP DIMENSION IV: SATISFACTION MMC 7 REPORTING PERIOD First Quarter SOcond Quarter Third Quartsr Fourth Quarter Monthly Average First Quarter Second Quarter Third Quarter Fourth Quarter Monthly Average Totals: Totals: 1111__J (C) c+ (I) rr) ' ro c+ Eligible Medicaid Population (PSP Not In Man. Care) Numb's. of Unique Cases Number of Admissions INPATIENT TREND Days Average of Length of Care Stay' Admissions Per Thoussnd Days of Cars Per Thousand Number of Unique Cases Number of PHP Admissions Avenge PHP Days of PHP Length of Admissions Care Per PHP Star Per Th d Th d PHP Days of Care CRISIS RESIDENTIAL TREND REPORT CRISIS STABILIZATION TREND REPORT Eligible Medicaid Population (P3P Not In Man. Care) Number of Unique Cases Numbor of Admissions Average Length of Admissions Stay Per Thousand Days of Care Per Thousand Number of Unique Cases Number of Crisis Stab. Admissions Total 0 Cds. Stab. Sent Hours Cris. Stab. Admissions Per 1000 Units of Cfill. Stab. Thousand PHP TREND REPORT REPORT Days of Cara QIPMP DIMENSION V: SERVICE UTILIZATION MMC 8 ComMUTify I stimili Hotpit.1 Cr461 Reskiential C.rwitet CriIII Slabilisition Cervites TOTALS: .0 %Ott Ri.,t1t)R. A il PkirtifUll EXPENDITURE TARGET MONITORING This Reporting Period - to Date Performance to Target — - • -- - Unditputed Disputed Undisputed Disputed Days of D. of Dsys of Days of Number of Core or Number of Care es Disputed Number of Care or Number of Csre or Disputed Perrone of Undisputed Units of Undisputed Disputed Units if Aggregate Core Total Mendel Care Undisputed Units of Undisputed Disputed Units of Aggregate Care Total Potential Core TarM Adminions Service Aggregate Care Out Admissions Service Cut (Pending) Coot L1.611117 Admissions Serrke Aft_regote Car. Cost _ Admissions _ Service _ Cott (Pending) Coot LiabSity_ _ ripenditure Target E,...4.nd -0 Sa Di r1 U:1 cf• C1 al a, ID jIPMP DIMENSION V: EXPENDITURE TARGETS MMC 9 BOARD: REPORTING PERIOD REVIEWS AND RELATED ACTIVITIES THIS REPORT PERIOD YEAR TO DATE PERFORMANCE TO CAP HOLD-PENDING Auregote Cod of Nunekr of Reviews Ramble, or - Sr Activities WIcleh Activities Whkh Have Been Dose Hove Peen Amount jilted to DWI Rut Not Yet Wiled Coaducted Rut NO Number of Reviews or for Reviews or Total Hanker of Thu Amount Ditkd to Amount of Board Pending Yet Idled Pending Adivities Conducted Activitks conducted Reviews or Adivtdes DMII for Reviews or Reimbursement Determination of Determination of During This Report During Mb Report Condedied Year to Activities Conducted Cop for Review. Percent of Cap Recipient Medicaid Redolent Medicaid Period Period Dale Year to Date and /Wichita Earned io Date Sides Eligibilit t • 1 INPATIENT PREADMISSION REVIEWS ONLY 1 , III Face-to-Face Phone TOTALS INPATIENT CON'T STAY CARE MGT. ONLY Recipient Admitted Through Another Board Home Board Does Con't Stay Revkws INPATIENT TOTAL EPISODE MANAGEMENT Admission Prrscreening Approval and Continuing Stay Reviews INPATIENT RETROSPECTIVE REVIEWS PliP PREADMISSION REVIEWS ll (Admission Diverted) , ' I . Face-lo-Face Phone TOTALS PIIP EPISODE MANAGEMENT Admission Prescreening Approval and All Continuing Stay Reviews PIIP RETROSPECTIVE REVIEWS , TOTAL "1:1 e—f- c+ t'O IN) as a (1) r+ CO QIPMP DIMENSION V: EXPENDITURE TARGETS MMC 1'0 ATTACHMENT B Page 1 MONITORING INFORMATION REQUIREMENTS This Attachment identifies summary reporting requirements and contains copies of required reports, as follows: I. Reporting requirements from minimum data set covering activity, client demographics and gross cost of services: a. A semi-annual aggregate report (format attched on page submitted on diskette, DCH Sub-Element/Cost Report.) b. A Year-end aggregate report, as described above. c. At year-end, a data file which aggregates minimum data set activity and client demographic information to an 'individual record for each client served during the fiscal year. This data file will contain a record for each consumer, utilizing Social Security number as the unique consumer identifier. d. At year-end, a data file which identifies gross cost for each sub-element for which activity is required. II. Performance Indicator System Reports (attached) -- Reporting dates, report formats and instructions are included as pages 3 through 16 of this Attachment B. III. Death Report IV. Managed Care Monitoring Reports (Attached) Other DD Population Attachment B Page 2 I. CMH Sub-Element/Cost Report FY 1996-97 CMHSP: Oct.-Mar. Completed By: Oct.-Sept. _ MI-C Population Due April 30 Due December 31 Population Program Element/ Cases Units Total Costs Cases Units Total Costs Cases Units Total Costs Total Costs Sub-Elements Inpatient Bd Managed Local Inpt ._ Bd Managed State Inpt Residential Eld Managed Residential . St or Other -Bd Mg Res _ Bd Managed -Crisis Res. Supported Independence . Day Program Partial Hosp Psychosocial Rehab Ctr ... Other Day Programs: Outpatient Clinic Services — Emergency Services • Supportive Service Assertive Comm Trtmt Crisis Stabilization Team Comm Treatment Team . Client Services Mgmt Family Supp/Hm Based Integrated Emp Serv Comm Integration Sew - _ Respite Res Services Prevention - .. Direct Service Models • Other Service Models v.. ' .y. . 4 ei . 4- — , . Board Administration .. . ' . ' •44 . ••• .. 4,1 4.' .. _.: , ..... ., .. . .., . Population Total .i i...-k_ Attachment B Page 3 II. Michigan Mission Based Performance Indicator System - 1.0 A. Access: Penetration Rates Due: 7/31/97 B. Access: Timeliness(Inpatient Screening) Due: 4/30/97 12/31/97 C. Access: Timeliness Due: 4/30/97 7/31/97 D. Access: Denial/Appeal Due: 4/30/97 7/31/97 E. Recipient Rights Complaints Due: 4/30/97 7/31/97 F. Inpatient Recidivism Due: 12/31/97 G. Level of Functioning Data 1. Due: 4/30/97 2. Data to be submitted electronically will include client records which include the following information: social security number, Medicaid number, demographic and service utilization data as required by the minimum data set and level of functioning data. The level of functioning data would include: Child and Adolescent Functional Assessment Scale Required administration: All new requests for service for children and adolescents ages 5 through 17. Required reporting to DCH: 8 child functioning subscales (Role Performance - School/work; Role Performance - Home,;Role Performance - Community; Behavior toward others, Moods/emotions; Self-Harmful behavior; Substance Use; Thinking) 2 care giver subscales (Using a clinician perceived composite of the care givers) (Material Needs; Family/social support) Attachment B Page 4 Behavior and Symptom Identification Scale Required administration: 1. All new non-emergent requests for service for adults with a mental illness 2. At the annual review date for ongoing cases Required reporting to DCH: 5 functioning subscales, from the BASIS-32 (Relation to self and others, daily living and role functioning, depression and anxiety, impulsive and addictive behavior, and psychosis) Inventory for Client and Agency Planning: Required administration: 1. All new non-emergent requests for service for persons with developmental disabilities 2. At the annual review date for ongoing cases Required reporting to DCH: 7 functioning subscales (Adaptive Behavior: Motor skills, Social & communication skills, Personal living skills, Community living skills; Ma!adaptive Behavior: Self injury/stereotyped/withdrawn, Offensive/uncooperative, Disruptive/destructive/hurts others) Folstein Mini-Mental State Examination:(This would be supplemental to the BASIS-32 for persons suspected of having dementia.) Required administration: 1. All new non-emergent requests for service for persons with or suspicion of dementia 2. At the annual review date for ongoing cases Required reporting to DCH: Single score H. All other data for the computation of performance indicators will be derived from other data reporting requirements contained elsewhere in this contract (e.g., the calculation of cost per case for specific diagnostic and age subgroups will be calculated from the minimum data set information submitted electronically by the CMHSPs.) Persons Served 1990 Census Attachment B Page 5 ACCESS: PENETRATION RATES (1-5) CMHSP NAME: Time Period: 4/1/97 - 6130/97 Persons Aged <18 r , . Persons Aged 65+ A Persons of Ethnic Minorities - , ; Persons Aged 18+ with SMI > rxte , Persons Aged <18 „. N.? with SED , Definitions: 1. Persons aged 18+ with a Serious Mental Illness are those persons with the following diagnostic categories: Schizophrenia and other Psychotic Disorders (295.)oc; 297.1; 297.3; 298.8; 298.9) Mood Disorders or Major Depressions and Bipolar Disorders (296.xx) Dementia (290.xx) Panic Disorder, Phobias and Obsessive Compulsive Disorder (300.xx) Somatization Disorder (300.81) Antisocial Personality Disorder (301.7) Attachment B Page 6 ACCESS: PENETRATION RATES (1-5) Definitions Page 2 2. Definition of Children with a Serious Emotional Disturbance -- Pursuant to Section 1912 © of the Public Service Act, as amended by Public Law 102-321 "children with a serious emotional disturbance" are persons: From birth up to age 18, The definition of serious emotional disturbance in children is restricted to persons up to age 18. Who currently or at any time during the past year, The reference year in each of the definitions refers to a continuous 12-month period because this is a frequently used interval in epidemiological research and because it relates closely to commonly used planning cycles. Have had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria specified within DSM-IV, American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, or DSM-IV. These disorders include any mental disorder (including those of biological etiology) listed in DSM-IV or their 1CD-9-CM equivalent (and subsequent revisions), with the exception of DSM-III-R "V" codes, substance use, and developmental disorders, which are excluded, unless they co-occur with another diagnosable serious emotional disturbance. All of these disorders have episodic, recurrent, or persistent features; however, they vary in terms of severity and disabling effects. That resulted in functional impairment which substantially interferes with or limits the child's role or functioning in family, school, or community activities. Functional impairment is defined as difficulties that substantially interferes with or limit a child or adolescent from achieving or maintaining one or more developmentally-appropriate social, behavioral, cognitive, communicative, or adaptive skills. Functional impairments of episodic, recurrent, and continuous duration are included unless they are temporary and expected responses to stressful events in the environment. Children who would have met functional impairment criteria during the reference year without the benefit of treatment or other support services are included in this definition. Attachment B Page 7 ACCESS - TIMELINESS/INPATIENT SCREENING (6) CMHSP NAME: Time Periods: 10/1/96 - 3/31/97 4/1/97 - 9/30/97 .- , .,...", ,,-.. ..x z - NumbeofEmergncy liumber4., *an , ReferralsOompieted Within Reteri1SCampJeted Within 1nptlen1ScmenIflgDu1ngthe hreeHours ortess ., . Attachment B Page 8 ACCESS: TIMELINESS (7,8,9) CMHSP NAME: • Time Periods: 1/1/97 - 3131/97 411197 - 6/30/97 I .Persons .Avg:*Days I Persons Average Number of Mays , 'fificeivia , ,... ,. , . . . . . . , .. .., .. MIC MIA <65 MIA 65+ DD <18 DD 18+ 'TOTAL Definitions: 1. Days are calendar days. 2. First request is a request by the individual, family, legal guardian, or referral source which results in the scheduling of a face to face assessment with a professional. 3. Non-emergent assessment and services excludes pre-admission screening for and receipt of psychiatric in-patient care. 4. Non-emergent assessment by a professional must be done face to face for the purpose of determining appropriateness for ongoing service. Average days between request and assessment should not include no show or cancellation dates. 5. Ongoing service includes any recommended service, including case management, respite care, etc. It excludes supplemental assessment services Total #Persons Requestin rid Attachment B Page 9 ACCESS: DENIALJAPPEAL (io) CMHSP NAME: Time Periods: 1011/96 - 3/31/97 4/1/97 - 6/30197 Total # Persons Assessed but Not Authorize twice NOTE: 1. Section 330.1705 of Public Act 258 of 1974 as revised, was intended to capture requests for initial entry into the CMHSP. Requests for changes in the levels of care received are governed by other sections of the Code. Attachment B Page 10 Definitions: Persons receiving supported employment: Persons who have accessed supported employment services (individual job coach, enclave, mobile crews, and/or transitional employment) for whom the CMHSP expects to provide ongoing, long term supports which would generally include two contacts per month with mental health staff which assist in an individual maintaining employment. Continuous Employment Continuous employment includes breaks in employment for two weeks or less if the break was due to a planned job change with the same or new employer. Integrated Work Setting "Integrated work setting means job sites where either- (1)(1) Most employees are not disabled; and (ii) an individual with the most severe disabilities interacts on a regular basis, in the performance of job duties with employees who are not disabled; and (iii) if an individual with the most severe disabilities are part of a distinct work group of only individuals with disabilities, the work group should consist of no more than 8 individuals; or (2)if there are no other employees or the only other employees are individuals who are part of a work group... the individual with the most severe disabilities interacts on a regular basis, in the performance of job duties, with individuals who are not disabled, including members of the general public." (February 18, 1994 Federal Register) Enclave Consists of a small group (8 or less) of individuals with disabilities working within a business or factory. Supervision and training may be combined or separate positions. Preferably supervision and training would be provided by the employer but may be provided by the service provider agency. Mobile Crew Consists of a small group (8 or less) of individuals who move from site to site to perform work. The crew has their own equipment. Job training and supervision are usually the responsibility of the service provider agency. Attachment B Page 13. Transitional Employment A model of supported employment specific to persons with mental illness. It involves multiple part-time work placements with community-based employers, paid by the employer. Support services are provided by a psychosocial club house program prior to and concurrent with the transitional employment experiences. Long term support would be available through the psychosocial club house for subsequent full-time placements. 2 SUPPORTED EMPLOYMENT REPORT Participants on: March 31 June 30 CLIENT POPULATION : Persons with Developmental Disabilities BOARD Attachment s Page. 12 INDIVIDUAL PLACEMENTS — Total Number of Number Number Number Number Individual of Minimum Employed with Placements: Persons Wage or 6 Months Employer Above Medical Benefits 30 or More Hours 20-29 Hours 10-19 Hours Less than 10 Hours ENCLAVES Number Number Number Number with Number of of Minimum Working Employer Enclaves: Persons Wage or 6 Months Medical Benefits Above 30 or More Hours 20-29 Hours 10-19 Hours Less than 10 Hours MOBILE CREWS Number Number Number Number with Number of of Minimum Working Employer Mobile Crews: Persons Wage 6 Months Medical Benefits or Above 30 or More Hours 20-39 Hours 10-19 Hours Less than 10 Hours DAY PROGRAM Number of Persons in Day Activity programs: Number of Persons in Work Activity programs: Number of Persons in "Type C" Day programs: Notes: 1) Persons who participated in both supported employment and day program on the date of data collection should be included in the supported employment category only. 2) Persons who particiapted in more than one type of day program on the date of the data collection should be counted only once. Attachment B Page 13 BOARD CLIENT POPULATION:PmmomswWWWWIIIImmm SUPPORTED EMPLOYMENT REPORT Participants on: March 31 June 30 INDIVIDUAL PLACEMENTS Total Number of Number Number Number Number Individual of Minimum Employed with Placements: Persons Wage or 6 Months Employer Above Medical Benefits 30 or More Hours 20-29 Hours 10-19 Hours Less than 10 Hours ENCLAVE - Number Number Number Number with Number of of Minimum Working Employer Enclaves: Persons Wage or 6 Months Medical Benefits , Above 30 or More Hours 20-29 Hours 10-19 Hours Less than 10 Hours MOBILE CREWS Number Number Number Number with Number of of Minimum Working Employer Mobile Crews: Persons Wage 6 Months Medical Benefits or Above 30 or More Hours 20-39 Hours 10-19 Hours Less than 10 Hours . TRANSMONAL EMPLOYMENT Number of Persons in Number Number Number Number with Transitional of Minimum Working Employer Employment: Persons Wage or 6 Months Medical Benefits Above 30 or More Hours 20-29 Hours 10-19 Hours Less than 10 Hours CONSUMER RUN BUSINESSES Number of persons employed in consumer owned and run businesses, including Fairweather Lodge Businesses: jSCharged.,ErOnil tent Percentl of Persons ReEidMitt Within:45DaySL- Attachment B Page 14 OUTCOME: INPATIENT RECIDIVISM (30) CMHSP NAME: Time Periods: 1/1/97 - 3/31/97 411/97 -9/30/97 itPersons 'Discharged an Readmitte Whin 15Days 3.0 Ana Inpatient Un NOTES: 1. The nUmber of persons screened and admitted includes admisions to All Psychiatric Hospital. It is Not limited to persons who are Medicaid eligible only. 2. This data is intended to capture Admissions and Readmissions, Not Transfers to another psychiatric hospital. Attachment B Page 15 RECIPIENT RIGHTS COMPLAINTS (n,23,29) CMHSP NAME: Time Periods: 111/97 - 3/31/97 4/1/97 - 6/30/97 Dignity and Respect Treatment Suited to Condition TOTAL of ALL Recipient Rights Complaints Regardless of Category Attachment B Page 16 III. Semi-Annual Aggregated Report of Death Community Mental Health Board: Report Date:_ Population: MI # Deaths This Period # Deaths Year to Date AGE I AGE Cause of 18& 19-35 36-60 61+ 18& 19-35 36-60 61+ TOTAL Death Under Under Suicide Homicide ACCIDENT -- (Please enter data in the appropriate box below.) While Under Program Supervision Not Under Program Supervision "Natural Causes" TOTAL COMMENTS: Instructions: If a board has recorded deaths in BOTH POPULATIONS, TWO reports will be required - ONE for persons with MI and ONE for persons with DD. Boards may utilize another format, provided all information is included. "Natural Causes" refers to deaths occurring as a result of a disease process in which death is one anticipated outcome. Reports are due on APRIL 30 for the period October 1 through March 31 and on DECEMBER 31 for the period April 1 through September 30. Use EITHER the YEAR TO DATE or the THIS PERIOD columns for the April 30 report. DD DUMMY: I. Managed Care Monitoring Reports -V C. CI) rP CID o• CD 1$ 0 r:rJ 3 :3 REPORTING PERIOD APPLICATION OF CLINICAL CRITERIA Inpatient Reviews PHP Reviews Of Number Of Number Conducted, Of Number Percent (%) of Conducted, Of Number Percent (%) of Number of Monitored- • Cases Number of PI-1P Monitored- Cases Total Number of Reviews Evaluated, Monitored- Total Number of Reviews Evaluated, Monitored- Inpatient Monitored- Number That Evaluated That PHP Reviews Monitored- Number That Evaluated That Reviews Evaluated Were Handled Were Handled Conducted Evaluated Were Handled Were Handled Conducted This Through According to According To During This Through According to According To Report Period Internal QI Published UM Published UM Report Period Internal QI Published UM Published UM (Count) Process (Count) Criteria (Count) Criteria (Count) Process (Count) Criteria (Count) Criteria COORDINATION OF CARE WITH PRIMARY PHYSICIAN OR RESPONSIBLE HEALTH CARE PLAN Screening and Reviews Significant Changes Of Cases Monitored- Evaluated and Which had a Of Cases Primary Care Percent (%) of Number of Monitored- Physician or Cases Cases Evaluated in Of Number of Responsible Monitored- Monitored- Which there had Of Total Cases Health Plan, the Evaluated in Evaluated been Significant Number of Monitored- Number in Which There Through Of Cases Changes, the Cases, the Evaluataed„ the Which There was Timely Internal Qi Monitored- Number in Percent (%) of Total Number of Number That Number Who was Timely Notice (Within Processes for Evaluated, the Which There Cases Cases Screened Were had an Notice to Standards) to Timely Number of was Timely Monitored- - Reviewed for Monitored- Identified Primary Care Physician or Notification to Cases in Which Notice to Evaluated in Inpatient or NIP Evaluated Primary Care Provider - Responsible Physician/Healt There had been Physician or Which Notice to Care During Through Physician or Responsible Health Plan of h Plan of Significant Health Plan of Physician of Report Period Internal QI Responsible Health Plan of Case Changes Changes Changes Changes Met (Count) Process (Count) Health Plan Disposition Disposition (Count) _ (Count) (Count) Standard 1--• QIPMP DIMENSION II: ATTRIBUTES OF CARE MMC I A ttsruKtiNG PERIOD RELAPSE/RECIDIVISM RATES - DETAIL ANALYSIS Of Number Of Number Discharged, Reviewed, Of Number Number Number of Number of Reviewed, Readmitted These Readmits Number of Within 15 Total Days of Readmits Deemed Readmits • Days of Readmission Reviewed Warranted (i.e. Deemed Discharge to a Recidivism Cart Attributed Through CMH not due to Unnecessary Number of General Rate (13 to Hospital of Clinical premature Had First Care Discharges Hospital Divided by A Discharge Staffing or discharge, poor Episode Been During Report Psychiatric Expressed as During this Internal QI discharge Better Handled Hospital (of Discharge) Name Period Unit %) Report Period Process planning, etc.) or Managed - . _ • - TOTALS •- "V 01 c-P (C)et- SU co S CO QIPMP DIMENSION H: ATTRIBUTES OF CARE MMC 2 ' BOARD: Recipient's Name Date of Last Continuing Stay Review Date of Next Scheduled Continuing Stay Review N.1 1.••nn 8 luawq3241V 1 REPORTING PERIOD Out-of-State Children's Psychiatric inpatient Placement Activity Out-of-State Inpatient Facility Name Date of Admission OA (0 1-1 MMC 3 OIPMP DIMENSION V: SERVICE UTILIZATION BOARD: REPORTING PERIOD CMH BOARD CREDENTIALING AND PRIVILEGING PROGRAM FOR MEDICAID MANAGED MENTAL HEALTH CARE Number Authorized By Number By Discipline e Total Number of t Staff Authorized to •a 1 1 1 1 1 I .Q •V s o Conduct These z e Activities Reviews 0 , Inpatient Pre-Screening Inpatient Continuing Stay Reviews PHP Pre-Screening PHP Continuing Stay Reviews Reconsiderations c-1- m CO ClIPMP DIMENSION II: ATTRIBUTES OF CARE MMC 4 IMAM): REPORTING PERIOD CMH INFORMAL CONSUMER RECONSIDERATION ACTIVITY RELATED TO MEDICAID MANAGED CARE Number of Consumer Number of Consumer Total Number of Reconsideration Reconsideration Number of Grievances or Requests or Grievances Requests or Grievances Administrative Objections or Regarding CMH Regarding CMH PHP Complaints Lodged Complaints Handled Inpatient Decisions Decisions Handled Relating to CMH Through CMH Internal Handled Through CMH Through CMH Clinical Execution of Medicaid Dispute Resolution Clinical Review System Review System During Managed Care Duties System This Report During Report Period , Report Period During Report Period Period c+ IV go =- •—• a OD I. QIPMP DIMENSION III: APPEALS AND RECONSIDERATIONS MMC 5 ksitt I Silva rierKILFLP PROVIDER REQUEST FOR RECONSIDERATION OF CIVIH SCREENING DECISIONS Appealing, Party: Primary Care Physician or Responsible Health Plan Treating Psychiatrist Hospital/Facility Other TOTALS: Number of Number of Number of Number et Number of Requests Mamba of Number of Number of Requests Number of Number of Number of Requests MI 0411 Percent reS) Number of Requests CIVAI CMN PerCent ('4) for Recormideration ChM OM Percent (4) for Reconsideration aill CM Percent r4) for Reconsideration Deciii" Dectik" a si°"' for Reconsideration Decb6ns Mid*" d peak" of Partial Decisions Decisions of Decisions of Partial Decisions Decisions of Decisions of Inpatient Changed Upheld Chsnged Changed Upheld Changed — C mged Upheld Changed —0 Changed Upheld Changed of Inpatient nospitalization to vitalization liPorl Upon Upon Upon UPon Upon Upon upon Upon Upon Upon Upon Pre-Screening Reconsides, Reconsida- Reconsider. Continuing Stay Reconsider- Reconsider- Reconsider- Pre-Screening Reconsider- ReCOnsider. Reconsider- Continued Stay Reconsider- Reconsider- Reconsider. Decisions Won 'don Won Decisions Won stion Won Decisions ation ation ation Decisions orlon anon ation • r+ tt:1 t-t-fD f's3 a CD e+ QIPNIP DIMENSION III: APPEALS AND RECONSIDERATIONS '11IMC 6 Provider/Referral Source Number Surveyed: Number Responding: Survey Period: Number of Respondents Giving This Response 8 ;uaw147224V S. -tr ar CD CA3 nr..rtnt I IPIRi CLKIUU Strongly Agree 6 5 Agree Strongly Mame 4 3 2 1 CMIH responded promptly to requests to referrals and service requests. CMH staff provided timely feedback regarding disposition of referrals or service contacts. CMH helped referred individuals get the right type of services for their problems CMH staff were knowledgeable and competent. Communication with CMH on mutual clients was satisfactory. In general, I was satisfied with the service provided by CMH. 1 I I 1_ 1 QIPMP DIMENSION IV: SATISFACTION MMC 7 First Quarter Second Quarter Third Quarter Fourth Quarter Monthly Average First Quarter Second Quarter Third Quarter Fourth Quarter Totals: 11L1 -t7 flo c+ fD A Iv 3 fD Inr.ol WE% Ir,111,1,1J1/ CRISIS RESIDENTIAL TREND REPORT CRISIS STABILIZATION TREND REPORT Eligible Medicaid Population (PSP & Not in Men. Caro) Number of Unique Cases Number of Admissions Average Length of Admissions Stay Per Thousand Days of Care Per Thousand Number of Unique Cases Number of Crisis Stab. Admissions Totalli Cris. Stab. Serv Hours CrIs. Stab. Admissions Per 1000 Units of Cris. Stab. Th Days of Cam INPATIENT TREND REPORT PHP TREND REPORT Eligible Medicaid Population (PSP & Not In Mon. Care) Number of Unique Cases Number of Admissions Average Length of Admissions Star Per Thousand Days of Care Per Th d Number of Unique Cases Number of PHP Admissions PHP Days of Care Average Length of PHP Star PHP Admissions Per Thousand Days of PHP Care Per Thousand Days of COMP 111111 Monthly Average Totals: QIPNIP DIMENSION V: SERVICE UTILIZATION MMC - Commemity (nsstient Pereisl Huang Crisie Residential Services Cries Stebilisstion Services SVA REPORTING PERIOD EXPENDITURE TARGET MONITORING _ - This Reporting Period . Year to Date. Performance to Target - - - Undleputed Disputed Undisputed Disputed ' Ow if Dogs of Dm of Days of Number of Coro or Numb,,.! Cent or Divvied Number of Car,., Numb.,.! Core or Disputed Percent of Undisputed Units of Undisputed Disputed Units of Aggregate Cure Taut Mendel Csre Undisputed Unite of Undisputed Disputed Unita of Aggregate Core Told Mendel Core T Admissions Service Aggregate Core Cut Adsniselons Service ._ Cut frending) Cost LiebiNty Admissions Sinks Aggregate Core Cat Admissions Servke Cul (Pendia') Cut WAN.' _ Espenditure Toted Enessairered 11111 -CY cu c+ tia 0.• iv =- 01 a CD CC1 jIPMP DIMENSION V: EXPENDITURE TARGETS MMC 9 BOARD: MAIM I ligesKil)11 RECONSIDERATIONS APPEALS OUT OF STATE PLACEMENT REVIEWS TOTAL CD ON S CD CX, REVIEWS AND RELATED ACTIVITIES THIS REPORT PERIOD YEAR TO DATE PERFORMANCE TO CAP HOLD-PENDING AsIcregate Cat of Nember of Reviews Reviews or Sr Activities Windt Activities Winch . Hare Dees Done Have Deco Amount iilled to DMH Ihn NM Yet Billed Cowthteted Rot Nil Number of Reviews sr for Reviews or Tool Number of Total AntoeM Billed to Amount of Board Pawling Yet Billed Pewit.% Activiiki Conflicted Attivides Conducled Reviews or Activities DMII for Reviews or Reintborsement DMennsination of Determined.. of putintnit Britoil Dodos Ms Report Conducted Yes, to Activides Osttlected Cop for Reviews Perron of Cop Recipient Medleold Recipient Medlesid Period Period Dole Year to Date mod AMAIN ranted to Rote Stole, IAN INPATIENT PREADMISSION REVIEWS ONLY • Face-to-Face Phone TOTALS INPATIENT CON'T STAY CARE MGT. ONLY Recipient Admitted Through Another Board Home Board Does Con's Stay Reviews INPATIENT TOTAL EPISODE MANAGEMENT Admission Prescreening Approval and Continuing Stay Reviews INPATIENT RETROSPECTIVE REVIEWS PHP PREADMISSION REVIEWS _ (Admission Diverted) • Face-to-Face Phone TOTALS PUP EPISODE MANAGEMENT Admission Prescreening Approval and AU Continuing Stay Reviews PUP RETROSPECTIVE REVIEWS ' TOTAL I. QIPMP DIMENSION V: EXPENDITURE TARGETS tIMC fe. C-1 ATTACHMENT C TO THE DCH/CMH CONTRACT 1996-97 MEDICAID MANAGED MENTAL HEALTH CARE Revised as of 1/1/97 Following is a list of the supporting documents and materials that describe the responsibilities and procedures required under the Medicaid managed care program. 1. Inpatient Review Procedures: This document describes the procedures involved in a psychiatric inpatient episode, including pre-admission screening by CMH, CMH responsibilities for continued stay and retrospective reviews and payment authorization, out-of-state children psychiatric inpatient placements, and the requirements for CMH to monitor the utilization of psychiatric inpatient services. 2. Partial Hospitalization Review Procedures: These documents describe standards and procedures for conducting admission screening reviews, continued stay reviews, and days of care Medicaid payment authorization. 3. Coordination with Primary Physician: These materials outline the communication and coordination between the physical health provider and the mental health provider. 4. Coordination with Substance Abuse: This guideline delineates the minimum requirements for the scope of written agreements between CMHSPs and Substance Abuse Coordinating Agencies. 5. Coordination with Health Plans for Developmental Disabilities: This model agreement describes the requirements for the areas of shared responsibilities between the Health Plans (HMOs, Clinic Plans, Qualified Health Plans) and the CMHSP for DD services. 6. Coordination with Health Plans: This model agreement describes the requirements for the areas of shared responsibilities between the Health Plans and the CMHSP for behavioral health services. 7. Utilization Management Criteria - Level of Care Determination: These materials include SI/IS criteria for the following Levels of Care: Inpatient Admission - Adults, Child and Adolescent Inpatient Continued Stay Intensive Crisis Residential - Adults, Child and Adolescent Partial Hospitalization Admission - Adults, Child/Adolescent Partial Hospitalization Continued Stay Crisis Stabilization Services 8. Monitoring and Evaluation: These documents describe the requirements for monitoring, reporting, and improvement planning activities by CMH and oversight responsibilities of DCH. DCH/CMH Contract 1996-97 Medicaid Managed Mental Health Care Attachment C Psychiatric Inpatient Preadmission and Episode Management Review Michigan Department of Community Health June 15, 1995 Revised January 1, 1996 Revised October 1, 1996 'C-2 C-3 MEDICAID MANAGED MENTAL HEALTH CARE Psychiatric Inpatient Review and Authorization The local designated community-based mental health agency provides a single point of entry and responsibility to manage the mental health services for Medicaid recipients enrolled in the Physician Sponsor Plan and those not enrolled in a managed primary health care arrangement. These responsibilities will be expanded to all Medicaid recipients, including those enrolled with a Health Maintenance Organization or Clinic Plan, as of 7 /1/97 1-he local community-based mental health agency will be the gatekeeper to hospital-based services. Management responsibilities will include: pre-admission screening for psychiatric inpatient hospital services to determine whether alternative services are appropriate and available • provision of, or referral to, alternative services to inpatient • psychiatric inpatient admission authorization, conducting continued stay reviews and retrospective reviews, and Medicaid payment authorization communication with the primary physician, HMO, Clinic Plan, Qualified Health Plan (Health Plan) where possible Psychiatric Inpatient Screening, Review and Payment Authorization Overview On August 1, 1995, CMH agencies began to provide a single point of entry to psychiatric inpatient services for all Medicaid recipients not enrolled in an HMO or Clinic Plan. CMH agencies provide a pre-admission screening of Medicaid recipients experiencing psychiatric crises to determine if an admission is medically necessary or to determine if alternative services are appropriate and available. On January 1, 1996, CMH assumed responsibility for psychiatric inpatient admission authorization and for continuing stay reviews and retrospective reviews for the purpose of authorizing Medicaid payment. Beginning 3/31/97 CMH will be responsible for authorizing Medicaid payment for psychiatric inpatient services in community hospitals for all Medicaid recipients. Pre-Admission Screening 1. CMH is mandated by the Mental Health Code to provide mental health emergency services 24 hours per day, 7 days per week. These services are designed to meet the need for immediate intervention to individuals who are experiencing an acute mental health related crisis. 2. All psychiatric inpatient requests or referrals by, or on behalf of, Medicaid recipients, must be pre-screened by CMH. a. Emergency referrals from the community, such as by physicians, other mental health Inpatient Review Procedures Page 4 practitioners, law enforcement and jails for persons awaiting adjudication, whenever possible, must be directed to the designated CMH Emergency Services program. In most instances, this will be the CMH Emergency Services for the county of residence of the Medicaid recipient. If the recipient is in crisis when visiting another county, the GMH in that county, as appropriate to the crisis, will conduct the screening on behalf of the other CMH and will coordinate with the CMH in the recipient's county of residence. b. Hospital and Emergency Room staff must contact the CMH for the CMH Emergency Services to conduct a pre-admission screening prior to any decision to admit or refer the Medicaid recipient to a psychiatric inpatient program. In most instances, this will be the CMH Emergency Services for the county of residence of the Medicaid recipient. However, if the recipient is visiting from another county and the hospital does not have an agreement with the recipient's local CMH, the CMH where the hospital is located will conduct the screening and authorize the admission and coordinate care with the CMH in the recipient's county of residence. c. Non-emergency referrals must be directed to the CMH Screening/assessment service in the recipient's county of residence. d. The Hospital must review the admission information to ensure that the CMH has certified the need for admission (MSA form 4756 or equivalent). 3. The pre-admission screening review by CMH will determine the acuity of illness and medical necessity for inpatient care or alternative level of care. The screening review results in one of the following dispositions: a. Determination that the intensity of service necessary for the individual is psychiatric inpatient. CMH will recommend admission and, as needed, refer the recipient to an enrolled Medicaid hospital for such services and complete MSA form 4756. b. Determination that an alternative crisis service is appropriate and available. CMH to refer to or provide such service. c. Determination that the individual is able to resume daily functioning activities with general mental health outpatient and support services. Referral to appropriate mental health service. d. Determination that the individual is in need of other non-mental health services, such as substance abuse treatment. CMH shall provide or refer the individual to appropriate provider. e. Determination that the crisis was resolved through CMH emergency services activity and no further service is required. CMH will refer the recipient back to the primary physician or Health Plan. Inpatient Review Procedures C-5 Page 5 4. Until 7/1/97, for HMO or Clinic Plan enrolled Medicaid recipients, CMH must contact the HMO or Clinic Plan for direction on the disposition. After7/1/97, CMH, where possible, should contact the HMO or Clinic Plan for information to assist in making the determination and disposition. 5. If the recipient is from another CMH service area and inpatient admission is being considered, the CMH conducting the screening must contact the other CMH to finalize the disposition. 6. CMH will conduct the screening using the statewide procedures and standards of practice for assessing severity of illness and intensity of service criteria. These criteria are included in a later section of this attachment. See Utilization Management Criteria - Level of Care Determination Guidelines for the inpatient criteria for Adults and for Child/Adolescent. 7. The screening assessment is to be done by staff qualified according to existing Type 21 standards. The CMH Clinical Screening staff shall be assessed through the CMH Personnel and/or Credentialing/Privileging process as competent to perform these screening reviews. Qualifications should take into account both education and clinical experience. Preferred qualifications include Clinical Social Work, Psychology, Psychiatric Nursing, Medicine. 8. The pre-admission screening may be conducted by phone with the provider or through face-to-face assessment with the recipient. The preferred alternative is a face-to-face assessment as this provides the opportunity for a more thorough assessment and review of the appropriate level of care. A face-to-face assessment may be conducted in the community, at a CMH facility, or at a hospital emergency room. 9. CMH will use triage principles to respond to the urgency of the crisis. The performance standard for emergency referrals is that the pre-admission review is to be conducted within 3 hours of the referral/request. The performance standard for non-emergent situations is that pre-admission reviews are to be completed within seven (7) calendar days of the request, with consideration of the urgency of the request generating a more rapid response. 10. If the Medicaid recipient presents with both mental health and substance abuse problems, CMH must coordinate their assessment with the Substance Abuse treatment system, including the regional Center for Diagnosis and Referral if required. Referral options should be based on the predominant treatment need and best approach to meet the needs of persons with coexisting conditions. Inpatient Review Procedures 6-6 Page 6 Admission Authorization 1. If inpatient admission is authorized, CMH will provide the hospital with an admission authorization number. 2. CMH will provide the hospital with appropriate clinical information and other necessary documentation that they have screened the admission and have authorized the need for an inpatient admission. Such documentation includes the MSA form number 4756. For elective admissions for persons under the age of 21 the MSA 4486 is used instead of form MSA 4756.* For emergent admissions for persons under the age of 21, CMH completes MSA 4756 and the hospital treatment team is responsible for completing MSA 4416 (or equivalent). 3. CMH will set up the continued stay review mechanisms and days of care authorization procedure with the hospital, including setting the date of the first continued stay review. 4. CMH will notify the HMO, Clinic Plan, PSP sponsor or primary physician, if the recipient has one, of the disposition. 5. If the recipient is from another CMH service area, the CMH conducting the pre-admission review must contact the home county CMH to determine responsibilities for conducting continued stay reviews. 6. If the hospital proceeds with admission without CMH prescreening the inpatient, services are not a covered Medicaid benefit. 7. If the hospital proceeds with admission against the CMH determination, the hospital and/or attending psychiatrist may request reconsideration of the CMH determination. Episode Management: Continued Stay Reviews and Discharge Planning 1. Continued Stay Reviews a. The medical necessity to continue in inpatient level of care and the days of inpatient stay are reviewed using an assessment of severity of illness and intensity of services. b. The Continued Stay Review also includes a review of the estimated length of stay and discharge planning efforts. c. The continued stay review is done by a qualified CMH Clinician Reviewer. d. The CMH should document their review and notify the hospital of the determination. e. If the recipient no longer needs the level of care provided by the inpatient program, the CMH Clinician Reviewer will inform the hospital that days of care payment by Medicaid will not be authorized. As necessary, CMH staff will be involved in * or equivalent Inpatient Review Procedures C-7 Page 7 expediting the discharge plan. Days of care provided beyond the date approved by CMH will be denied for Medicaid payment. 2. Timelines and Procedures for Continued Stay Reviews a. On the review date set by the CMH Clinician Reviewer at the time of the last review, the hospital initiates the review of clinical status, treatment progress, and discharge plans. b. The preferred process is for the CMH Clinician Reviewer to conduct the review at the hospital with the appropriate treatment/utilization review staff. This provides an opportunity for CMH to be actively involved in the treatment/discharge planning. c. The continued stay review can also be conducted by telephone, with the contact being initiated by the hospital. d. It is expected that most determinations will be made immediately by the CMH Clinician Reviewer. The performance standard for conducting inpatient continued stay reviews is that all determinations will be made within two work days from initial contact by the hospital. e. If at the time of the continued stay review date the recipient has been discharged, the CMH Clinician Reviewer reviews the days of care between the last review date and the discharge date. f. If the CMH is conducting the reviews on behalf of the home CMH, they must notify the home CMH of all authorization decisions made. 3. Scope of Review The continued stay review includes clinicaVbehavior status, assessment of risk factors, medication response, response to treatment, discharge plans, and projected length of stay. The CMH reviewer applies the SVIS review criteria and his/her best clinical judgement. 4. Review Frequency a. At the time of the admission review the CMH Clinician Reviewer assigns the appropriate date for the continued stay review based upon the admission assessment and clinical judgement. b. If the case is determined as continuing to need the inpatient level of care, the CMH CR assigns a new continued stay review date. c. All cases where the episode has reached the point which is twice the average LOS for that hospital will automatically be reviewed by the CMH Clinical Supervisor and/or CMH Psychiatrist. Inpatient Review Procedures C-8 Page 8 5. Discharge Planning CMH, in discussion with the hospital, will make a determination whether the Medicaid recipient is in need of CMH services after the inpatient episode. CMH will arrange for the outpatient appointment and for other CMH services as needed. Enrollment in Medicaid During or After the Inpatient Episode 1. Medicaid recipients who are on spend-down are expected to be screened and reviewed in the same way as fully enrolled Medicaid recipients. 2. For persons who are determined by the referral source to be eligible for Medicaid, it is recommended that the hospital involve CMH in the case during the admission and inpatient episode. 3. Retrospective Reviews: a. CMH will conduct a review of persons who become Medicaid recipients during or after the inpatient episode. Whenever possible, if the recipient is still in the inpatient unit, CMH conducts an admission review and then places them on a continued stay review schedule. b. If it is too far into the episode or the person has been discharged, CMH will conduct the Medicaid payment authorization through a retrospective review of the entire episode. c. Retrospective reviews which require a review of the entire record will be conducted within 30 days from the date of request by the hospital. d. Retrospective reviews include a determination that the admission was necessary according to the statewide standards for Severity of Illness and Intensity of Services. e. Each day of care is reviewed in accordance with SI/IS criteria to determine if the inpatient day was necessary. f. The retrospective review is to be documented and the hospital notified of the determination. The CMH issues the admission authorization number and payment authorization number. Medicaid Payment Authorization Medicaid payment to the hospital and treating psychiatrist requires the following: 1. CMH must have approved the admission through a pre-admission screening review. CMH must have issued documentation of the need for the admission (MSA 4756) to the hospital. Inpatient Review Procedures C-9 Page 9 2. CMH must have issued an admission authorization number to the hospital/physician. This number is required for the physician billing to Medicaid. 3. CMH must have conducted continuing stay reviews or a retrospective review and issued a Medicaid payment authorization number which includes the number of days that are authorized for payment by Medicaid. The admission authorization number and the payment authorization number are provided to CMH through a statewide number generation process. Admission Authorization Number: When CMH has approved the admission and when CMH establishes that the hospital accepted and admitted the Medicaid recipient, an admission authorization number will be generated. The CMH will provide the following information in order for a number to be generated: Recipient Medicaid Number Medicaid Level of Care code Other Insurance Hospital Medicaid Number CMH Authorizing the Admission County of Residence Admission Date Payment Authorization Number: After discharge, and occasionally during the episode for interim payment purposes, a payment authorization number must be generated. The CMH will provide the following information in order for a number to be generated: Admission Authorization Number Discharge Date Days approved for payment Days denied for payment Discharge Diagnosis Discharge Plan Category Reconsiderations/Appeals 1. Medicaid recipients have the right to request a hearing through the Hearings Officer at the local FIA Office (PA 280 Administrative Rule Part 9 R 400.901). As a step in the pre- hearing procedure there may be a supervisory review and/or a pre-hearing conference. For appeals of CMH pre-admission screening, continued stay and retrospective review decisions, it is expected that CMH will participate in these hearings at the local FIA Office, as well as at subsequent hearings at MSA. CMH recipients also have rights to file a complaint through the CMH Recipients Rights Office. c:io Inpatient Review Procedures Page 10 2. The hospital or treating psychiatrist may request reconsideration of CMH pre-admission screening decision. The physician must contact CMH within 48 hours to request a second review (reconsideration) of the screening decision. The request shall state the reasons why the physician disagrees with the CMH decision. The reconsideration review shall be conducted by a CMH Clinical Supervisor and/or CMH Psychiatrist. The performance standard for reconsideration reviews is that the reconsideration will be completed within three week days, excluding holidays. CMH will notify the hospital/physician of the reconsideration determination. If the physician/hospital disagrees with the reconsideration decision the physician/hospital may appeal to MSA. 3. The hospital or treating psychiatrist has rights to request reconsideration of CMH continued stay decisions. The hospital or physician must contact CMH within two work days to request a second review of the days of care denial. The request shall state the reasons why the hospital/physician disagrees with the CMH decision. The reconsideration review will be conducted by a CMH Clinical Supervisor and/or CMH psychiatrist. The performance standard for reconsideration reviews is that the reconsideration will be completed within three week days (Monday - Fri day) , excluding holidays CMH will notify the hospital/physician of the reconsideration determination. If the recipient remained in the inpatient program beyond the days of care authorized by CMH and the physician disagrees with the reconsideration decision they may appeal to MSA. 4. The hospital or treating psychiatrist have rights to request reconsideration of CMH retrospective review decisions. The request must be in writing and be submitted to CMH within 30 days of notification of the retrospective determination. The request shall state the reasons why the hospital/physician disagrees with the CMH decision. The reconsideration review will be conducted by a CMH Clinical Supervisor and/or CMH psychiatrist. The reconsideration will be completed within 30 work days. CMH will notify the hospital/physician of the reconsideration determination. If the physician/hospital disagrees with the reconsideration decision the physician/hospital may appeal to MSA. 5. If the hospital/physician does not request a reconsideration within the timelines this is a basis for denial. Inpatient Review Procedures C41 Page 11 6. If the CMH reconsideration results in an adverse determination, that is one in which the provider is not authorized for Medicaid payment for services already provided, CMH is to put the decision in writing to the hospital with a copy to DCH/MSA Hearings Officer and to DCH/Behavioral Health. The information must follow the required format and contain the rationale for the CMH decision as well as details about the provider, the service dates under consideration, and the recipient. The information provided to DCH/MSA must also contain information about the contact person at CMH whom MSA staff can contact for the scheduling of appeal conferences and hearings in the event that the determination is appealed. 7. For all levels of the MSA appeals process the CMHB needs to identify the "expert" who will be able to represent the CMHB and explain and defend the CMH determination. Based upon scheduling, the CMHB may also need to identify an individual who will be the back-up "expert". Monitoring of Utilization and Quality of Care 1. CMH must implement monitoring mechanisms to ensure the quality of the pre-admission screening reviews, continued stay review and retrospective reviews with respect to the following dimensions: a. Consistent application of the assessment procedures. b. Timeliness of response to pre-admission screening referrals/requests (emergency referrals within 3 hours and non-emergent situations within 7 days). c. Staff consistency and competency in conducting screening reviews. d. Timeliness of continued stay reviews (within 3 days , Monday - Friday) and retrospective reviews (within 30 days). e. Timeliness of response to requests for reconsideration (within 3 days, , Monday- Friday). 2. CMH shall monitor and review by disposition category pre-admission screening reviews. 3. CMH shall monitor and review continued stay and retrospective review decisions. 4. Medicaid recipients who are readmitted to a psychiatric inpatient unit within 15 days of discharge from an inpatient episode must be reviewed through the CMH utilization review or risk management process. The CMH must monitor, through its established QI process, the patterns (if any) surrounding such occurrences and develop plans of improvement to deal with such situations/patterns as necessary. ' 5. DCH will monitor the pre-admission screening and inpatient episode management process and performance against the monitoring and evaluation plan through the site review for Medicaid certification, including a review of a sample of screening and review Inpatient Review Procedures C-12 Page 12 records, and through quarterly reports from CMH. If DCH determines there are compliance issues, the CMHSP will develop an improvement plan within 30 days, with compliance expected within 180 days. 6. Hospitals shall provide CMH with reports on use/attendance by Medicaid recipients and by persons who are likely to have some or all of the psychiatric inpatient episode be eligible for Medicaid payment. 7. CMH must monitor utilization of inpatient days and expected Medicaid payment against the local target. Utilization reports that should be monitored at a local level include: a. CMH Review Activity Volume • b. CMH Denial Activity c. Use (admissions, days, LOS) by diagnostic categories d. Use summarized by type of Medicaid Managed Care Plan (i.e. QHP, HMO, Clinic Plan, PSP and non-managed care recipients): admissions, days, days/admission e. Use by persons with co-existing substance abuse symptoms: admissions, days, days/admission f. Readmission patterns, with particular reference to readmission within 15 days g. Summary of types of discharge plans h. Trend reports of use over time (e.g. admissions, days of care, length of stay) I. Expected Medicaid payment 8. DCH must monitor utilization and expected Medicaid payment against the state target. If there are performance concerns with a CMHSP, DCH will work with the CMHSP to develop a plan of correction as needed. Inpatient Review Procedures C-13 Page 13 Out-of-State Children Psychiatric Inpatient Placements Overview There are approximately 15 children/adolescents from Michigan who are receiving Medicaid funded psychiatric inpatient services from out-of-state non-enrolled hospitals. These admissions are planned admissions with the referral/request for out-of-state hospitalization coming from Probate/Juvenile Court and local MSA staff. As these admissions are elective, they are subject to CMH Certification of Need review and approval prior to admission. It is state policy that children should receive mental health treatment within their home community and, as needed, from psychiatric hospitals that are closest to home. It is Medicaid policy that placement at an out-of-state facility should only be considered as a last resort and that there is no in-state option to meet the needs of the Medicaid recipient. Effective August 1, 1995 through Medicaid policy and under the terms of the Interagency Agreement for Medicaid managed mental health care, CMH assumed responsibility for the admission authorization, continued stay reviews and Medicaid payment authorizations for these placements. Medicaid payments will continue to be made on fee-for-service basis using a Medicaid determined percentage of the provider's charge. These payments are not included in the Medicaid managed mental health care expenditure target and will not count against the DCH/CMH targets. Referrals: The pre-admission process requires that the case be reviewed to determine that there is no in-state option to meet the needs of the child. In many cases the child has experienced a number of hospitalizations or placements. Usually there are other significant factors beyond the psychiatric condition, including substance abuse, juvenile delinquency, and severe disruptive behaviors and other conduct disorders. Many of the referrals originate outside CMH, typically coming from Probate Court staff or local FIA staff. The referral source retains responsibility for the case through the prior authorization process and the inpatient episode. The referral source is required to obtain CMH determination that the inpatient services as provided by this out-of-state facility are necessary and that there are no in-state resources to meet the need of the child. Most of these children are Medicaid eligible at the time of referral. CMH is required to conduct the preadmission authorization for all Medicaid eligible children. The hospital is required to pursue third party liability. The referral source is responsible for determining the likelihood that the child will become a Medicaid recipient. If it is highly likely that the child will become a Medicaid recipient, the referral source should contact CMH to conduct a pre-admission review. Inpatient Review Procedures C-14 Page 14 Admission Authorization: CMH will continue to conduct the required pre-admission Certification of Need reviews for under 21 elective admissions (Medicaid Manual Chapter II, pages 24-27, MSA form 4486). In addition, CMH will need to make the determination that the proposed out-of-state facility is the only appropriate program to meet the needs of the recipient and that it is eligible for Medicaid funding. CMH will complete a Medicaid authorization for the admission, approve a certain number of days up to 90 days eligible for Medicaid payment, and establish the next review date. CMH notifies the referral source, the hospital, and Medicaid about these authorizations. The referral source is responsible for setting up the admission with the facility. CMH is responsible for providing the authorization information to Medical Services Administration, Bureau of Medicaid Operations/Miscellaneous Transactions Unit, with a copy to DCH/Behavioral Health. The authorization information is made up of an authorization letter and a copy of MSA 4486. The letter is to include information about the recipient (name, number, date of birth), name and address of the out-of-state hospital, admission date or proposed admission date, number of days authorized for Medicaid payment, 'reason why the out-of-state placement is the only option, and name and contact person of the CMH making the authorization for Medicaid payment. Continued Stay Reviews: The hospital is expected to provide ongoing information to the referral source during the episode. The hospital needs to work closely with the referral source in discharge planning. It is preferred, though not required, that the hospital provide updates to CMH prior to the continued stay review date. The hospital initiates the continued stay review with CMH prior to the expiration date of the original authorization. The hospital provides CMH with information from the clinical record, to include clinical information about the treatment plan, progress in treatment, current status of the recipient, discharge plans, and need for continued treatment. CMH conducts the continued stay review, contacting the hospital as needed for additional information. CMH certifies the need for continued stay using MSA-4486. Based upon the review CMH then authorizes additional days of stay, up to a maximum of 90 days. CMH notifies the referral source, the hospital and Medicaid about these authorizations. CMH sends the authorization to MSA Bureau of Medicaid Operations/ Miscellaneous Transactions Unit. Retrospective Reviews: Occasionally a child becomes eligible after the admission. As soon as the hospital receives notice of the Medicaid eligibility approval, they are required to contact CMH to conduct an admission and days of stay Medicaid payment authorization. These retrospective reviews are similar in scope as the continued stay review, though it may be necessary for the hospital to send a copy of the complete medical record for the CMH review and determination. Inpatient Review Procedures C45 Page 15 Reconsiderations: If the CMH makes an adverse determination, the hospital may request a reconsideration of that decision. The hospital must contact CMH within 48 hours to request a second review. The request shall state the reasons why the hospital disagrees with the CMH decision. The reconsideration shall be conducted by a CMH Clinical Supervisor and/or CMH psychiatrist. As these out-of-state hospitals are not enrolled providers with the Michigan Medicaid program they do not have rights to appeal through MSA. The Medicaid recipient does have complaint and appeal rights through the local FIA office. Monitoring: Performance Standard: All Medicaid recipients referred for placement in out-of-state children/adolescent psychiatric hospitals or psychiatric units of hospitals will be reviewed and approved by CMH. Inpatient Review Procedures Page 16 MEDICAID MANAGED MENTAL HEALTH CARE INPATIENT REVIEW AND AUTHORIZATION PROCESS CHECKLIST FOR CONDUCTING PRE-ADMISSION SCREENINGS TYPE OF SCREENING Date Time Phone Face-to-face Where conducted: Community CMH site Hospital ER Other Response time by CMH Name of person conducting screening, qualification Who requested screening PRE-ADMISSION SCREENING GENERAL INFORMATION Name of patient, date of birth, sex Address County of Residence Medicaid number and current Medicaid status Other insurance Medicaid Managed Care Status (Level of care) Primary Physician, Medicaid ID # Qualified Health Plan (QHP) HMO Clinic Plan No primary physician Likelihood of becoming Medicaid covered Spend-down Dual-coverage Appears to meet Medicaid qualifications None Name of treating psychiatrist, Medicaid ID # CMHB Status Open Closed Never been open in CMH CMH Case Manager/Clinician GENERAL CLINICAL CONSIDERATIONS What were factors that precipitated crisis Is the person mentally ill Inpatient Review Procedures C47 Page 17 Diagnosis and how substantiated Medication assessment Past psychiatric treatment history including hospitalizations Medical history or other medical problems SEVERITY OF ILLNESS ASSESSMENT Severe psychotic signs/symptoms Disruptions of self-care and independent functioning Harm to Self - Suicidal assessment Harm to Others - Homicidal potential, Aggressive behaviors/dangerousness • Drug/medication complications INTENSITY OF SERVICES What alternatives to inpatient were considered and why rejected SPECIAL CONSIDERATIONS Dual diagnosis MI/SA: * Substance abuse status and history * Medical clearance by CM11 or ER obtained prior to admission * Factors that resulted in psych admission rather than referral to SA Child/Adolescent * Developmental limitations/strengths * Family/Parental level of commitment to participate in treatment * MSA or Probate Court involvement Medical Conditions * Does recipient require combined medical and psychiatric treatment DISPOSITION Inpatient Admission Name of hospital referred to, Medicaid ID #, Phone # Voluntary or Involuntary MSA-4756 sent to hospital Admission authorization number issued to hospital Alternative crisis service Name of program Type of program Referred to outpatient/support services Name of program Type of program Crisis resolved through ES contact - no services needed COMMUNICATION/COORDINATION Other CMH for out-of-county cases handled by your CMH Name of CMH/ County Contacted during disposition Inpatient Review Procedures C48 8 Page 18 Time Contact person at other CMH Communicated disposition Decision regarding ongoing episode management responsibilities QHPs, HMOs and Clinic Plans Contacted during determination Notified of disposition PSP and Other Primary Physicians Notified of disposition PREADMISSION DETERMINATION - RECONSIDERATION/APPEAL Who requested reconsideration Date/time of request Who conducted reconsideration Reconsideration decision and date/time Date appeal filed with MSA Disposition of Appeal INPATIENT CONTINUED STAY REVIEWS GENERAL INFORMATION Date, time Who conducted the review Where conducted Hospital name and # Name of person providing information Name of patient Medicaid number Name, # of treating physician Date of admission Date of last review GENERAL CONSIDERATIONS Changes in diagnosis Changes in level of functioning SEVERITY OF ILLNESS AND RISK ASSESSMENT Changes in psychotic signs/symptoms Changes in self-care and independent functioning Changes in Suicidal risk Changes in Homicidal risk Inpatient Review Procedures C-19 Page 19 STATUS OF TREATMENT Participation in treatment and progress towards goals Medication changes/response, side effects Assessment of natural support system Assessment of community resources Necessity for continued inpatient treatment Estimate for length of stay Discharge plans DETERMINATION Dates/Days of attendance approved Days denied Next review date Discharge Date Total days approved Medicaid authorization number issued COMMUNICATION/COORDINATION Other CMH for out-of-county cases handled by your CMH Name of CMH/ County Contact person at other CMH Communicated authorization decisions Notified of discharge planning OHPs, HMOs and Clinic Plans Notified of discharge plans, as needed PSP and Other Primary Physicians Notified of discharge plans, as needed DAYS OF CARE DETERMINATION - RECONSIDERATION Who requested reconsideration Date/time of request Basis for reconsideration Who conducted reconsideration Decision and date/time Date appeal filed with MSA Disposition of appeal RETROSPECTIVE REVIEWS Date/time of request by hospital Name, # of hospital Who requested review Why requested Retro Medicaid eligibility Other insurance ran out Inpatient Review Procedures C-20 Page 20 Date/Time of retrospective review Where conducted: CMH site Hospital Name of person conducting retrospective review GENERAL INFORMATION Name of patient, date of birth, sex Address County of Residence Medicaid number and current Medicaid status Medicaid eligibility Date Other insurance Medicaid Managed Care Status (level of care) Primary Physician, Medicaid ID # QHP HMO Clinic Plan No primary physician Admission Date Discharge Date Days of Stay Name of treating psychiatrist, Medicaid ID # CMHB Status Open Closed Never been open in CMH CMH Case Manager/Clinician WAS THE ADMISSION NECESSARY? GENERAL CLINICAL CONSIDERATIONS What were factors that precipitated crisis Diagnosis and how substantiated Medication assessment Past psychiatric treatment history including hospitalizations Medical history or other medical problems SEVERITY OF ILLNESS ASSESSMENT Severe psychotic signs/symptoms Disruptions of self-care and independent functioning Harm to Self - Suicidal assessment Harm to Others - Homicidal potential, Aggressive behaviors/dangerousness Drug/medication complications INTENSITY OF SERVICES What alternatives to inpatient were considered and why rejected Inpatient Review Procedures C-21 Page 21 SPECIAL CONSIDERATIONS Dual diagnosis MI/SA * Substance abuse status and history * Medical clearance by CMH or ER obtained prior to admission * Factors that resulted in psych admission rather than referral to SA Child/Adolescent * Developmental limitations/strengths * Family/Parental level of commitment to participate in treatment * MSA or Probate Court involvement Medical Conditions * Does recipient require combined medical and psychiatric treatment WERE THE DAYS OF STAY NECESSARY? GENERAL CONSIDERATIONS Did diagnosis justify services? Did level of functioning through the episode justify inpatient services SEVERITY OF ILLNESS AND RISK ASSESSMENT Did Severity of Illness level justify inpatient: Severity of psychotic signs/symptoms Severity of disruption to self-care and independent functioning Suicidal risk Homicidal risk Drug/medication complications STATUS OF TREATMENT - Were inpatient services necessary? Was there progress towards goals Medication changes/response, side effects Were alternative services appropriate/available Necessity for continued inpatient treatment Appropriateness of Discharge plans DETERMINATION Admission justified Dates/Days of attendance approved Days denied and reasons Total days approved Medicaid authorization number issued RETROSPECTIVE REVIEW - RECONSIDERATION Who requested reconsideration Date/time of request Basis for reconsideration Who conducted reconsideration Decision and date/time Date appeal filed with MSA Disposition of appeal DCH/CMH Contract 1996-97 Medicaid Managed Mental Health Care Attachment C MEDICAID MANAGED MENTAL HEALTH CARE PARTIAL HOSPITALIZATION REVIEW PROCEDURES Michigan Department of Community Health June 15, 1995 Revised January 1, 1996 Revised October 1, 1996 C-23 MEDICAID MANAGED MENTAL HEALTH PARTIAL HOSPITALIZATION REVIEW PROCEDURES FOR MEDICAID PAYMENT AUTHORIZATION Overview In August 1995, CMH agencies assumed responsibility to screen and approve Medicaid payment for Partial Hospitalization services provided through hospital outpatient programs for all Medicaid recipients except those enrolled in an HMO or Clinic Plan. Prior to August 1995, while there was no admission review for Medicaid recipients, there was a continued stay review by DMH at the 30th treatment day or 90 calendar days whichever occurred first. Through the review and Medicaid payment authorization process by CMH, it is expected that the hospital partial hospitalization programs can be incorporated into the continuum of treatment options, with the use of these services based upon level of need of the Medicaid recipient. It is expected that these programs will be used as an alternative to an inpatient admission, as well as a step-down to shorten the length of a psychiatric inpatient episode. Beginning 7/1/97 CMH responsibilities to authorize Medicaid payment for partial hospitalization services will be expanded to cover all Medicaid recipients, including those enrolled in Qualified Health Plans (QHPs), HMOs and Clinic Plans. Medicaid Definition of Partial Hospitalization To be eligible for partial hospitalization the recipient must be receiving active psychiatric treatment. Medicaid will only reimburse programs that are licensed as partial hospitalization programs. All reimbursement for services is included in the Medicaid payment except for the physician/psychiatrist services. Day care partial hospitalization must be tailored to the needs of each client. The clients are regularly scheduled for: minimum of five days per week; 6 or more hours per day and a minimum of one meal; recipient returns home or to a residential facility at night; primary services are therapy procedures as well as supervision; recipient will usually be self-care*and may need medication supervision only. The Medicaid Manual for hospitals also includes provisions for Medicaid coverage for partial hospitalization - night care. The definition is the same as day-care plus accommodation and two meals. (Medicaid Manual for Hospital Chapter III). * (ambulatory) C-24 Partial Hospitalization Reviews Page 2 ADMISSION REVIEW AND AUTHORIZATION PURPOSE To certify that admissions by Medicaid recipients to psychiatric partial hospitalization programs of hospitals are medically necessary. In order to ensure a consistent review process across the community-based mental health system, DCH/CMH has developed a set of guidelines for the review/authorization process and the assessment/criteria model. MEDICAID RECIPIENTS COVERED BY THESE PROCEDURES These procedures will be used for all Medicaid recipients who are in one of the following categories: a. Physician Sponsored Plans (PSP) b. Not enrolled in a managed care program c. Medicaid spend-down recipients d. As of 7/1/97 Medicaid recipients enrolled in HMOs, Clinic Plans, or other Qualified Health Plans In addition, these procedures will be used, in part, for Medicaid recipients with dual coverage where the other insurance does not cover some or all of the partial hospitalization services. Persons with dual coverage Medicare/Medicaid are not subject to admission or continued stay reviews for as long as the Medicare coverage is valid for these services. REFERRALS/REQUESTS FOR ADMISSION REVIEW All requests or referrals on behalf of Medicaid recipients for hospital partial hospitalization services must be reviewed and approved by CMH prior to the admission. a. Referrals from the community, such as by psychiatrists, hospitals, and other mental health practitioners, must be directed to the designated CMH Screening/Assessment Service in the recipient's county of residence. b. For Medicaid recipient's who are in a psychiatric inpatient program the hospital staff must contact the CMH Hospital liaison staff to request review of a proposed admission to a partial hospitalization program. Partial Hospitalization Reviews C-25 Page 3 ADMISSION REVIEW PROCESS 1. Admission Review a. The referral is screened using severity of illness and intensity of service dimensions to determine if an admission to a partial hospitalization service is the appropriate level of care for the severity of illness, or whether there are other services that are more appropriate to the recipient's condition. b. The partial hospitalization admission review is to be done by a qualified CMH Clinician Reviewer. If the admission is determined as necessary, it will be certified by the CMH Clinician Reviewer as authorized for Medicaid payment. c. The admission review may be conducted through a face-to-face assessment of the recipient or by phone with the referral source. The preferred alternative is a face-to- face assessment as this provides the opportunity for a more thorough assessment and review of the appropriate level of care. 2. Timelines The performance standards for conducting Partial Hospitalization admission reviews is that the review is to be completed within two work days for persons in inpatient programs and within five work days for community referrals. The CMH should use triage principles and urgency of need in determining how quickly to complete the determination. If the community referral is for a recipient who would otherwise need inpatient services, the CMH should conduct the review within two work days. Five work days is the maximum. 3. Determination a. Referral to Partial Hospitalization: 1. If it is determined that the intensity of service necessary for the recipient is partial hospitalization, the CMH Clinician Reviewer (CR) will refer the Medicaid recipient to an enrolled Medicaid hospital provider for such services. 2. CMH will notify the hospital of the referral and provide the hospital with pertinent clinical information. 3. CMH will provide the Medicaid authorization for the admission (MSA-4757) and establish the review cycle for the continued stay review. 4. If the CMH is conducting the pre-admission review on behalf of another CMH, they must contact the home CMH before finalizing the admission. The two CMHs need to decide who will be responsible for episode management. Partial Hospitalization Reviews C-26 Page 4 b. Alternatives: If it is determined that the recipient is not in need of the level of care provided by partial hospitalization, CMH will refer to or provide the alternative service. CMH will inform the referral source about the disposition of the assessment/referral. c. No Services Necessary: If it is determined that the recipient is not in need of services, CMH will refer the recipient to the primary physician. 4. Qualifications The CMH Clinician Reviewer must be assessed through the CMH Personnel and/or Credentialing/Privileging process as competent to perform these admission reviews. Qualifications should take into account both education and clinical experience. Staff must be qualified according to existing Type 21 standards. Preferred qualifications include Clinical Social Work, Psychology, Psychiatric Nursing, Medicine. CONTINUED STAY REVIEW AND AUTHORIZATION PURPOSE To certify that the days of care by Medicaid recipients in a psychiatric partial hospitalization program are medically necessary. CERTIFICATE OF NEED AND LICENSING STANDARDS In considering the continued stay review process, CMH should take into account the Michigan Partial Hospitalization Program requirements which include the following relevant standards: 1. Individual plans of service are to be reviewed and revised at least every five calendar days of treatment. 2. Clients are regularly scheduled to be treated for a minimum of 5 days per week. Clients may be served by the program less than 5 days per week during the 2 weeks immediately prior to the client's discharge from the program. 3. The average length of stay for adults shall not exceed 30 treatment days in any eight calendar week period. The average length of stay for children/adolescents shall not exceed 60 treatment days in any 16 calendar week period. Partial Hospitalization Reviews C-27 Page 5 PROCESS 1. Continued Stay Reviews a. The days of stay are reviewed using an assessment of severity of illness and intensity of services to determine if the days of attendance/care provided since the last review were medically necessary and appropriate at this level of care. b. The Continued Stay Review also includes a review of the estimated length of stay and discharge planning efforts. c. The continued stay review is done by a qualified CMH Clinician Reviewer. d. The CMH should document their continued stay review on MSA 4758 (or equivalent). e. If the recipient no longer needs the level of care provided by a partial hospitalization program, the CMH Clinician Reviewer will inform the hospital that days of care payment by Medicaid will not be authorized. As necessary, CMH staff will be involved in expediting the discharge plan. Days of care provided beyond the date approved by CMH will be denied for Medicaid payment. 2. Timelines and Procedures a. On the review date set by the CMH Clinician Reviewer at the time of the last review, the hospital initiates the review of clinical status and treatment provided since the last review. b. The preferred process is for the CMH Clinician Reviewer to conduct the review at the hospital with the appropriate treatment/utilization review staff. This provides an opportunity for CMH to be actively involved in the treatment/discharge planning. c. The continued stay review can also be conducted by telephone, with the contact being initiated by the hospital. d. It is expected that most determinations will be made immediately by the CMH Clinician Reviewer. All determinations will be made within two work days from initial contact by the hospital. e. If at the time of the continued stay review date the recipient has been discharged, the CMH Clinician Reviewer reviews the days of care between the last review date and the discharge date. 3. Scope of Review The continued stay review includes clinical/behavior status, assessment of risk factors, medication response, response to treatment, discharge plans, and projected length of stay. The CMH reviewer applies the review criteria and his/her best clinical judgement. Partial Hospitalization Reviews C-28 Page 6 4. Review Frequency a. At the time of the admission review the CMH Clinician Reviewer assigns the appropriate date for the continued stay review based upon the admission assessment and clinical judgement. b. If the case is determined as continuing to need partial hospital car q the CMH CR assigns a new continued stay review date. c. All cases where the episode has reached the point which is twice the average LOS for that hospital will automatically be reviewed by the CMH Clinical Supervisor and/or CMH Psychiatrist. 5. Determination a. The CMH reviewer may approve some or all of the days of care since the last review. CMH documents the decision on MSA-4758 or equivalent. b. If the case meets criteria for continuation of partial hospitalization services, the CMH CR informs the hospital and establishes the next review date. c. If an adverse decision is made the CMH CR notifies the hospital. 6. Qualifications The CMH Clinician Reviewer should be assessed through the CMH Personnel and/or Credentialing/Privileging process as competent to perform these continuing stay reviews. Qualifications should take into account both education and clinical experience. Preferred qualifications include Social Work, Psychology, Nursing. ENROLLMENT IN OR COVERAGE BY MEDICAID DURING OR AFTER THE PARTIAL HOSPITALIZATION EPISODE 1. Medicaid recipients who are on spend-down are expected to be reviewed in the same way as fully enrolled Medicaid recipients. 2. For persons who are determined by the hospital and CMH to be eligible for Medicaid, it is recommended that the hospital involve CMH in the case during the partial hospitalization episode consistent with the basic admission and continued stay review procedures. For the purposes of the Medicaid payment authorization, the hospital and CMH will have to wait until the person is enrolled in Medicaid. At that time, CMH may request to review the entire medical record for the partial hospitalization episode to make the payment authorization determination. Retrospective reviews include a determination that the admission was necessary and that each day of attendance/care was necessary. The retrospective review is documented through completion of MSA-4759.*The provider may request a reconsideration of this decision and if they disagree with the reconsideration they may appeal to MSA. * (or equivalent) Partial Hospitalization Reviews C-29 Page 7 3. For persons who have dual coverage, including Medicare/Medicaid, the hospital will involve CMH in the case at the point where the insurance coverage ends. At that time CMH will initiate a continued stay review process for the rest of the episode. RECONSIDERATIONS/APPEALS Medicaid providers (hospitals and psychiatrists) and recipients have rights to appeal review/authorization decisions. The review procedures incorporate secondary levels of review and reconsideration mechanisms internal to CMH. When those options have been exhausted, the hospital and/or recipient may appeal directly to MSA. MSA has three levels of appeal: Preliminary Conference, Bureau Conference, and Administrative Law Judge Hearing. CMH will provide written reports and make direct testimony available to MSA. DCH will provide assistance to MSA as requested. 1. Medicaid recipients have the right to request a hearing through the Hearings Officer at the local FIA Office. As a step in the pre-hearing procedure, there may be a supervisory review and/or a pre-hearing conference. It is expected that CMH will participate in these hearings at the local FIA Office, as well as at subsequent hearings at MSA. 2. The hospital or physician must contact CMH within two work days to request a second review of the admission denial. The request shall state the reasons why the physician disagrees with the CMH decision. The reconsideration review will be conducted by a CMH Clinical Supervisor and/or CMH psychiatrist. The reconsideration will be completed within five work days. CMH will notify the physician of the determination. 3. The hospital or treating psychiatrist have rights to request reconsideration of CMH continued stay decisions. The hospital or physician must contact CMH within two work days to request a second review of the days of care denial. The request shall state the reasons why the hospital/physician disagrees with the CMH decision. The reconsideration review will be conducted by a CMH Clinical Supervisor and/or CMH psychiatrist. The reconsideration will be completed within five work days. CMH will notify the hospital/physician of the determination. If the physician disagrees with the reconsideration decision they may appeal to MSA. 4. The hospital or treating psychiatrist have rights to request reconsideration of CMH retrospective review decisions. The request must be in writing and be submitted within 30 days of the CMH determination. The request shall state the reasons why they disagree with the CMH decision. CMH shall complete the review within 30 work days. CMH will notify the hospital/physician of the determination. If the hospital/physician disagrees with the reconsideration decision they may appeal to MSA. 5. If the hospital/physician does not request a reconsideration within the timelines this is a basis for denial. 6. If the CMH reconsideration results in an adverse determination, that is one in which the provider is not authorized for Medicaid payment for services already provided, CMH is to put the decision in writing to the hospital with a copy to DCH/MSA Hearings Officer and to Partial Hospitalization Reviews C-30 Page 8 DCH/Behavioral Health. The information must follow the required format and contain the rationale for the CMH decision as well as details about the provider, the service dates under consideration, and the recipient. The information provided to DCH/MSA must also contain information about the contact person at CMH whom MSA staff can contact for the scheduling of appeal conferences and hearings in the event that the determination is appealed. 7. For all levels of the MSA appeals process the CMHB needs to identify the "expert" who will be able to represent the CMHB and explain and defend the CMH determination. Based upon scheduling, the CMHB may also need to identify an individual who will be the back-up "expert". MONITORING Quality Reviews 1. CMH will establish review mechanisms consistent with a continuous quality improvement philosophy to: a. Validate the information provided by the hospital via telephone for admission and continued stay reviews through an audit of a sample of partial hospitalization records. b. Assure that admission and continuing stay reviews are conducted using the statewide procedures and standards of practice for assessing severity of illness and intensity of service. c. Assure assessments are conducted by qualified staff. d. Assure timeliness of response to admission referrals (2 days for inpatient referrals, 7 days for community referrals). e. Assure timeliness of response to reconsiderations (2 days) 2. CMH will monitor and review by disposition category pre-admission screening reviews. 3. CMH is expected to monitor and review the utilization patterns and expenditures for partial hospitalization services. Reporting Mechanisms CMH will develop record keeping, storage and retrieval/reporting mechanisms to meet the following needs: 1. Tracking each case through the review process of the partial hospitalization episode. Partial Hospitalization Reviews C-31 Page 9 2. Assignment of Medicaid payment authorizations and tracking expenditures authorized. 3. Providing quarterly/annual activity reports to DCH. 4. Profile/pattern data for denials; overall, by physician, and by hospital. 5. Quality indicators and Quality Improvement mechanisms. (Pg. C-91 Medicaid Managed Mental Health Care Program Quality Improvement & Performance Monitoring Plan). State Monitoring 1. DCH will monitor the pre-admission screening and inpatient episode management process and performance against the monitoring and evaluation plan through the site review for Medicaid certification, including a review of a sample of screening and review records, and through quarterly reports from CMH. If DCH determines there are compliance issues, the CMHSP will develop an improvement plan within 30 days, with compliance expected within 180 days. 2. DCH must monitor utilization and expected Medicaid payment against the state target. If there are performance concerns with a CMHSP, DCH will work with the CMHSP to develop a plan of correction as needed. C.-32 Partial Hospitalization Reviews Page 10 MEDICAID MANAGED MENTAL HEALTH CARE PARTIAL HOSPITALIZATION REVIEW AND AUTHORIZATION PROCESS CHECKLIST FOR CONDUCTING ADMISSION REVIEWS ADMISSION GENERAL INFORMATION Date of referraVrequest Name of referral source, identification # Where assessment conducted : Phone CMH site Hospital inpatient Name of person conducting review Name of patient, date of birth, sex Address County of residence Medicaid number and current Medicaid status Other Insurance Medicaid Managed Care Status (Level of Care): PSP physician, Medicaid ID # QHP, # HMO, # Clinic Plan, # Not enrolled in managed care Likelihood of becoming Medicaid covered Spend-down Dual coverage Appears to meet Medicaid qualifications None Name of treating psychiatrist, Medicaid ID # CMHB Status Open case with CMHB Closed Never been open in CMH CMHB Case Manager/Clinician GENERAL CLINICAL CONSIDERATIONS What were factors that precipitated request Is the person mentally ill Diagnosis Medication assessment Past treatment history including hospitalizations Partial Hospitalization Reviews 0-33 Page 11 SEVERITY OF ILLNESS ASSESSMENT Severe psychotic signs/symptoms Disruptions of self-care and independent functioning Harm to self - Suicidal assessment Harm to Others - Homicidal potential, Aggressive behaviors/dangerousness ' Drug/medication complications INTENSITY OF SERVICES What alternatives were considered and why rejected SPECIAL CONSIDERATIONS Dual diagnosis MI/SA * Substance abuse status and history * Factors that resulted in psych referral rather than referral to SA Child/adolescent * Family/parental commitment to participate in treatment * Developmental limitations/strengths * MSA or Probate Court involvement DISPOSITION Partial Hospitalization admission Name and # of hospital Admission date Expected intensity of attendance Next review date Admission approval MSA 4757 form sent to hospital Alternative service Name of program Type of program Referral completed No services needed COMMUNICATION/COORDINATION Other CMH for out-of-county cases handled by your CMH Name of CMH/ County Contacted during disposition Time Contact person at other CMH Communicated disposition Decision regarding ongoing episode management responsibilities QHPs, HMOs, Clinic Plans, PSPs and Other Primary Physicians Notified of disposition , Partial Hospitalization Reviews C-4 Page 12 RECONSIDERATION Who requested reconsideration Date/time of request Basis for reconsideration Who conducted reconsideration Decision and date/time Date appeal filed with MSA Disposition of appeal CONTINUED STAY REVIEWS GENERAL INFORMATION Date, time Who conducted the review Where conducted Hospital name and # Name of person providing information Name of patient Medicaid number Name, # of treating physician Date of admission Date of last review GENERAL CONSIDERATIONS Changes in diagnosis Changes in level of functioning SEVERITY OF ILLNESS AND RISK ASSESSMENT Changes in psychotic signs/symptoms Changes in self-care and independent functioning Changes in Suicidal risk Changes in Homicidal risk STATUS OF TREATMENT Participation in treatment and progress towards goals Medication changes/response, side effects Assessment of natural support system Assessment of community resources Necessity for continued partial hospitalization treatment Estimate for length of stay Discharge plans DETERMINATION Dates/Days of attendance approved Days denied Next review date Partial Hospitalization Reviews C-35 Page 13 Discharge Date Total days approved Medicaid form MSA 4758 issued ( or equivalent) COMMUNICATION/COORDINATION Other CMH for out-of-county cases handled by your CMH Name of CMH/ County Contact person at other CMH Communicated authorization decisions Notified of discharge planning QHPs, HMOs, Clinic Plans, PSPs and other Primary Physicians Notified of discharge plans, as needed RECONSIDERATION Who requested reconsideration Date/time of request Basis for reconsideration Who conducted reconsideration Decision and date/time Date appeal filed with MSA Disposition of appeal RETROSPECTIVE REVIEWS Date/time of request by hospital Name, # of hospital Who requested review Why requested Retro Medicaid eligibility Other insurance ran out Date/Time of retrospective review Where conducted: CMH site Hospital Name of person conducting retrospective review GENERAL INFORMATION Name of patient, date of birth, sex Address County of Residence Medicaid number and current Medicaid status Medicaid eligibility Date Other insurance Medicaid Managed Care Status Primary Physician, Medicaid ID # QHP Partial Hospitalization Reviews C-36 Page 14 HMO Clinic Plan No primary physician Admission Date Discharge Date Days of Stay Name of treating psychiatrist, Medicaid ID # CMHB Status Open Closed Never been open in CMH CMH Case Manager/Clinician WAS THE ADMISSION NECESSARY? GENERAL CLINICAL CONSIDERATIONS What were factors that precipitated need for admission Diagnosis and how substantiated Medication assessment Past psychiatric treatment history including hospitalizations Medical history or other medical problems SEVERITY OF ILLNESS ASSESSMENT Severe psychotic signs/symptoms Disruptions of self-care and independent functioning Harm to Self - Suicidal assessment Harm to Others - Homicidal potential, Aggressive behaviors/dangerousness Drug/medication complications INTENSITY OF SERVICES What alternatives to partial hospitalization were considered and why rejected SPECIAL CONSIDERATIONS Dual diagnosis MI/SA * Substance abuse status and history * Factors that resulted in psych admission rather than referral to SA Child/Adolescent * Developmental limitations/strengths * Family/Parental level of commitment to participate in treatment * MSA or Probate Court involvement Medical Conditions * Does recipient require combined medical and psychiatric treatment WERE THE DAYS OF STAY NECESSARY? Partial Hospitalization Reviews C-37 Page 15 GENERAL CONSIDERATIONS Did diagnosis justify services? Did level of functioning through the episode justify PHP services SEVERITY OF ILLNESS AND RISK ASSESSMENT Did Severity of Illness level justify PHP: Severity of psychotic signs/symptoms Severity of disruption to self-care and independent functioning Suicidal risk Homicidal risk Drug/medication complications STATUS OF TREATMENT Were partial hospitalization services necessary? Was there progress towards goals Medication changes/response, side effects Were alternative services appropriate/available Necessity for continued PHP treatment Appropriateness of Discharge plans RETROSPECTIVE REVIEW DETERMINATION Admission justified Dates/Days of attendance approved Days denied and reasons Total days approved Medicaid form MSA 4759 issued ( equi val ent) RETROSPECTIVE REVIEW - RECONSIDERATION Who requested reconsideration Date/time of request Basis for reconsideration Who conducted reconsideration Decision and date/time Date appeal filed with MSA Disposition of appeal C-38 MEDICAID MANAGED MENTAL HEALTH CARE Guideline for Coordination between Primary Physicians and CMH BACKGROUND The State of Michigan's Department of Community Health recognizes the need for improved management and coordination for health care and mental health services for persons served through the Medicaid program. The public mental health system, Community Mental Health, has a comprehensive network of community-based services which has served as the single point of entry and on-going service management for many Medicaid recipients. However, this service management has not been available to all Medicaid recipients. Of particular concern is coordination for psychiatric inpatient and partial hospitalization services. To promote better service coordination and a more efficient use of resources the State Department continues to pursue policies that will improve the coordination between physical and mental health care and to provide a more integrated and comprehensive mental health benefit for Medicaid recipients. A key component to the Medicaid managed mental health care initiative is the coordination and communication between the physical health provider and the mental health provider. This guideline describes the scope of such coordination between CMH and primary physicians. Coordination with other Health Plans (HMOs, Clinic Plans) are addressed in other sections of Attachment C. PSYCHIATRIC SERVICES BY PRIMARY PHYSICIANS (Non-psychiatrists) For Medicaid recipients not enrolled in a capitated plan (QHPs, HMOs, Clinic Plans) the Medicaid program reimburses psychiatric services personally rendered by a physician through Medicaid Type 10 or Type 11 categories. Services have to be provided directly by the physician except for psychological testing which must be ordered by the physician and performed by a psychologist. Medicaid reimburses only for services that are medically necessary. The Medicaid Bulletin provides the following guideline though exceptions are allowed if medically necessary: A physician may provide a maximum of five psychiatric visits per twelve months per recipient for any service or combination of services. The visit limitation does not include the initial interview and psychological testing. Coverage under the Medicaid program includes the following services: * Conjoint therapy * Diagnostic work-up * Family counseling * Individual and group psychotherapy, and * Psych-pharmacotherapy Medicaid does not cover marathon psychotherapy or sessions of less than 20 minutes. (Reference: Medicaid Manual for Practitioners, Chapter III) Physician/CMH Coordination Guideline C-39 Page 2 PSYCHIATRIC AND MENTAL HEALTH SERVICES PROVIDED BY FEDERALLY QUALIFIED HEALTH CENTERS (FOHC) Federally Qualified Health Centers (FQHC) are established to provide a broader array of health and mental health services. All FQHCs in Michigan are enrolled as PSPs and as an HMO. With respect to FQHC mental health services such encounters can be provided by health services persons other than physicians including nurses, psychologists, and clinical social workers. Mental health services are those of a psychologic or crisis intervention nature, or related to alcohol or drug abuse treatment. FQHCs also have federal requirements for the provision of case management. (Reference Medicaid Manual - Federally Qualified Health Centers and Indian Health Clinics) REFERRALS BY SPONSOR OR PRIMARY PHYSICIAN 1. The primary physician, including PSP Sponsors, for all Medicaid enrollees who need mental health services beyond that provided by the primary physician or FQHC, will refer as follows: a. Non-emergency cases may be referred directly to a psychiatrist or to the designated CMH Screening/Assessment Service in the recipient's county of residence. b. Emergency cases, whenever possible, will be immediately sent to the designated CMH Emergency Services Program in the recipient's county of residence. If the physician/psychiatrist sends the recipient directly to the hospital Emergency Room for assessment for psychiatric inpatient services, the physician/psychiatrist should contact CMH in order to initiate the CMH pre-admission review. 2. Physician referral will include: a. Applicable releases of information. b. Assessment of the need for mental health treatment, including mental health history, diagnoses, and treatment. C. Information about current and past physical health conditions, information from last annual physical, current diagnoses and treatment, current medications and recent lab work. 3. CMH will notify Sponsor or, where possible, the primary physician of Medicaid enrollees who self-refer for mental health services. For non-emergency cases Sponsor/primary physician will provide referral information (releases, health care assessment, medications, mental health treatment history). 4. CMH will also obtain releases as needed from the recipient in order to ensure communication and integration between the mental health and physical health providers. Physician/CMH Coordination Guideline Page 3 TREATMENT AND COMMUNICATION - GENERAL PRINCIPLES 1. CMH and Sponsor/Primary physician will provide regular communication with each other regarding the status of the recipient. 2. CMH and Sponsor/primary physician will inform each other of significant changes in status, of particular importance is prompt communication regarding medication changes and laboratory reports that might impact the treatment being provided by the other. 3. CMH is responsible for authorizing, through physician orders, pharmacy and laboratory services needed as part of the mental health treatment plan for services provided by CMH. 4. CMH will refer to the Sponsor/primary physician any health care needs that are identified by the mental health system in the course of treatment. 5. Physician to conduct annual physical and provide CMH with reports. 6. For persons with coexisting mental health and substance abuse conditions, CMH will coordinate with the Sponsor/primary physician and with the Substance Abuse treatment provider when the substance abuse provider is different from CMH. COMMUNICATION DURING MENTAL HEALTH TREATMENT Elospitalizations 1. CMH will notify the primary physician of the disposition of the pre-admission screening. For dispositions that result in admission this can be done by sending/faxing a copy of the completed Medicaid Certification for Inpatient Hospital Psychiatric Admission form. 2. CMH will notify the primary physician of the inpatient discharge date. If the Medicaid recipient has been determined by CMH to be in need of CMH services after the inpatient episode, CMH will notify the primary physician of the discharge plan, particularly if the primary provider is to be involved in the aftercare services. Outpatient Mental Health Treatment 1. Initial Evaluation: After the initial evaluation for non-emergency referrals CMH will provide the primary physician with information about the psychiatric diagnoses, medications prescribed, treatment to be provided, and any special concerns. 2. Medication: A key topic for communication between the mental health provider and the primary physical health provider is in the area of medications. CMH will notify the primary physician of medications prescribed, including levels of medication. CMH will also notify the physician about changes in types of medication and significant changes in the level of medication. CMH will notify the primary physician of problem laboratory results that indicate an impact on the recipient's overall health and treatment. Physician/CMH Coordination Guideline C-41 Page 4 3. Significant Changes in Status: CMH will notify the primary physician about significant changes in the status of the client. Examples include: * Suicidal behavior * Major changes in level of functioning * Discharge/termination of treatment Physical Health Treatment 1. Medication: The primary physician at the initial referral will have provided CMH with information about current medications. The primary physician will notify CMH about changes in medication for recipients receiving services from CMH, with particular emphasis on medications that are known to interact with medication prescribed for mental health purposes. 2. Significant Changes in Status: The primary physician will notify CMH about significant changes in the health of the recipient. Examples include: * Planned surgeries * Pregnancy * Other serious and persistent diseases or disorders * Problem laboratory results 3. Annual Physical Examination: The primary physician will conduct annual physical examinations and provide CMH with the reports. Type 10/11 Mental Health Services Some CMHSPs provide services through the Medicaid Provider Types 10 and 11, that is, the physician provider type. In particular CMH physicians provide psycho-pharmacotherapy on an outpatient basis to persons whose mental health condition can be met through this intervention. In addition CMH psychiatrists may also provide physician services for hospital- based psychiatric inpatient and partial hospitalization episodes. These physician services are billed through Medicaid Type 10/11 which requires a PSP authorization number on the invoice. The CMH and PSP need to develop procedures to be used by CMH to obtain this authorization for this subset of recipients and for these hospital- based psychiatric services. PROCESS 1. Know each other CMH should make available an informational packet about the local CMHSP for use by the physicians. This should include names of key persons that the physician will interact with. It is recommended that one person (with a back-up) at CMH be identified as the primary liaison person to the physician. The physician and these key staff need to meet as needed so that they know each other. The packet should include information about key programs (location, address, phone/fax numbers, brief description of services, hours of operation). Mechanisms will need to be developed to update this information. Physician/CMH Coordination Guideline C-42 Page 5 The physicians, particularly PSP Sponsors, should make available to CMH a similar informational packet to include names of physicians and key staff, address, phone/fax numbers, hours of operation, approximate number of Medicaid managed care caseload. 2. User Friendly Communication In developing working relationships the physicians and CMH should always look for user- friendly options. It is essential to identify the key information items that needs to be exchanged. The last thing we want to occur is more paperwork for two systems of care that are already overworked. CMH and the physician need to explore the use of fax communication and e-mail. Also existing forms (referral forms, authorization/certification, status reports etc,) should be used wherever possible. June 15, 1995 Revised October 1, 1996 Medicaid Managed Mental Health Care Coordination Between Mental Health and Substance Abuse Services for Medicaid Recipients with Coexisting Substance Abuse and Mental Illness Conditions The purpose of this attachment is to support state policy of coordination and collaboration between the public mental health service system and the public substance abuse service system. Beginning in FY 1994/95 both DPH/CSAS and DMH informed their respective local service systems to initiate a planning process to result in local interagency agreements between the Substance Abuse Coordinating Agency and the CMHSPs in their area. These local interagency agreements continue to be required under the state contract between DCH/Behavioral Health and CMH and the state contract between DCH/CSAS and the Coordinating Agencies in 1996/97. This attachment provides an outline for the scope of such local agreements between the CMHSP and the Substance Abuse Coordinating Agency for improving services to persons with coexisting conditions. Content Areas 1. Access. Assessment. Case Management and Referral Procedures shall be developed for the coordination between the CMHSP, with particular reference to the CMH Emergency Services, and the Substance Abuse Centers for Diagnosis and Referral (CDRs) and other Substance Abuse treatment providers. These procedures should recognize the importance of treating a person with coexisting conditions under a coordinated treatment plan. The procedures must address the following areas: a. Which agencies/sites will handle which cases for both crisis and non-crisis situations b. What are the hours of operation and the back-up provisions to access assessment and/or consultation c. Screening criteria and assessment tools to be used for assessing dual diagnosis d. Procedures for referral to outpatient, community-based residential services and inpatient, who does what with whom e. Coordinated discharge planning procedures to be used in conjunction with the hospital and residential detox providers f. Procedures for the determination of agency responsibilities on a case-by-case basis including the assignment of primary case coordination/management responsibility Coordination with Substance Abuse Page 2 g. Procedures for treatment plan development and coordination h. Reimbursement requirements necessary to support services provided I. Clinical treatment dispute mechanisms and procedures j. Administrative dispute resolution mechanisms and procedures k. Mechanisms for the exchange of information 2. Training and Staff Development The agreement between the CA and the CMH should establish provisions for cross- training of service providers in dual diagnosis assessment, treatment and coordination of services. 3. Collaboration a. The agreement shall specify mechanisms to do interagency planning, including where possible a delineation of priority areas. b. The agreement should specify areas of joint collaborative programming. c. The agreement should provide for mechanisms to exchange information to support referral and/or coordinated treatment planning on behalf of persons with coexisting conditions. d. The agreement should provide for regularly scheduled meetings between the Executive Directors of the CMHSP and the Coordinating Agency to review the activities and provisions of the local agreement, including at least an annual meeting of all the CMHs in the Substance Abuse Coordinating Agency catchment area. C-45 MEDICAID MANAGED MENTAL HEALTH CARE Coordination Between Community Mental Health and Health Plans Developmental Disabilities The purpose of this attachment is to support state policy of coordination between providers of Medicaid health care services. In 1996-97, Health Plans (HMOs, Clinic Plans, Qualified Health Plans) and Community Mental Health Services Programs (CMHSPs) will be expected to develop local written agreements that delineate the areas of shared responsibilities for Medicaid recipients. The purpose of these local agreements is to define coordination and collaboration between the agencies in order to promote and protect the health of Medicaid recipients. The agreements must include the following areas of shared responsibilities: Referral Interagency Assessment and Supports/Services Planning Emergency Services Pharmacy and laboratory service coordination Medical Coordination Quality Improvement coordination Data and reporting requirements Grievance and complaint resolution Dispute Resolution Under the contracts for 1997, the Health Plans will be required to have written agreements with CMHSPs. These agreements must incorporate and address all of the items and areas listed and described in the following model agreement for specialized developmental disability supports and services. January 1, 1997 C-:16 Model Agreement between Health Plan and CMHSP (Developmental Disabilities) Page 1 Model Agreement Between HEALTH PLAN and Local Developmental Disability Contractor (Community Mental Health Service Program, CMHSP) The agreements between the Health Plan (Health Maintenance Organizations, Clinic Plans, Qualified Health Plans) and the local developmental disability contractor (CMHSP) must incorporate and address all of the items and areas listed and described below. These standard provisions are as follows: --Legal Basis —Term of Agreement --Administration --Areas of Shared Responsibility --Referral —Interagency Assessment and Supports/Services Planning --Emergency Services —Pharmacy and laboratory service coordination --Medical Coordination —Quality Improvement coordination —Data and reporting requirements --Grievance and complaint resolution --Dispute Resolution —Indemnification --Governing Laws This agreement is made and entered into this day of , 19 by and between and . (Health Plan) (CMHSP) (1) Legal Basis Whereas, P.A. 352 of the Public Acts of 1996 permits the Department of Community Health to increase the enrollment of Medicaid eligible persons in qualified health plans on a capitated basis; and Whereas, in order to expand enrollment the Department of Community Health has established a competitive bid process that has resulted in contracts with health plans that are deemed to be qualified to provide specified health care services to Medicaid enrollees; and Whereas, specialized services for Medicaid enrollees who have developmental disabilities will be provided through arrangements between the Department of Community Health and selected developmental disability providers; and Whereas, Community Mental Health Service Programs, CMHSP, are designated as the Developmental Disability Provider under contract with the Department of Community Health and consistent with the Mental Health Code; and Model Agreement between Health Plan and CMHSP (Developmental Disabilities) Page 2 Whereas, Health Plans and CMHSPs should coordinate and collaborate efforts in order to promote and protect the health of Medicaid enrolled population; Now, therefore the Health Plan and the CMHSP agree as follows: (2) Term of Agreement This agreement will be effective 19 for a period not to exceed 12/31/98. The agreement will be subject to amendment due to changes in the contracts between the Department of Community Health and the Health Plan or the contract with the Community Mental Health Services Programs. Upon signed agreement of both parties, the provisions of this agreement will be extended for a time frame consistent with the contract period of the Health Plan and the Department of Community Health. Either party may cancel the agreement upon 30 day written notice. (3) Administration and Point of Authority The Health Plan shall designate in writing to the CMHSP the person who has authority to administer this agreement. The CMHSP shall designate in writing to the Health Plan the person who has authority to administer this agreement. (4) Areas of Shared Responsibility In order to provide the most efficient and coordinated services to Medicaid enrollees, the responsibilities of the Health Plan and CMHSP will include: (A) Referral Mutually Served Consumers This refers to Health Plan members who also receive CMH services. Mutual consumer groups will be defined according to clinical criteria agreed upon between the individual CMH and Health Plan. Services to be provided by the Health Plan and by CMH may vary for different clinically defined groups. Eligibility criteria for specialty developmental disability (DD) services are outlined in Attachment 1. It should be noted that persons who receive specialty developmental disability services also have a high likelihood of requiring behavioral health services. Entry to CMHSP Specialized Services for Persons with DD This is the process of obtaining CMHSP approval for a Health Plan member to receive specialized DD services from CMHSP. Specialized DD services means those unique services of CMHSP which support persons in community environments and/or provide alternatives to, or decrease the need for, Intermediate Care Facilities for persons with Mental Retardation (ICFs/MR) which includes State DD Centers and Alternative Intermediate Services for C-47 C-48 Model Agreement between Health Plan and CMHSP (Developmental Disabilities) Page 3 Persons with Mental Retardation (AlS/MR) homes. These might include such services as specialized residential services, day program services, outpatient Mental Health Clinic services, supportive services (e.g., family support, supported independent living), etc. Services To Be Provided (Benefit Packages and Limitations) The intent of establishing written procedures between Health Plans and CMHSP Programs is to assure service coordination and continuity of care for persons receiving services from both organizations. Therefore it is essential that the parties define the service/coverage package which will be provided by each party to mutual consumers. This must also specify any limitations on amounts of services, including but not restricted to: * emergency services * inpatient hospital, and outpatient services by type of outpatient service * intermittent/short term LTC nursing facility stays * physician, especially neurological assessments and treatment, diagnostics, and orders for therapies * pharmacy, particularly drugs used in seizure and/or behavioral management and OTC and non-prescription items commonly ordered for consumers with DD * laboratory services * dental services * therapies (physical, occupational, speech) * Mental Health Clinic Services * home health services, including hourly nursing * medical equipment and supplies, and assistive technology * specialized DD services, including home and community-based care, crisis stabilization, and long-term supports * personal care services, including Home Help and specialized Mental Health personal care * transportation to medical services & to Mental Health services (B) Interagency Assessment and Supports/Services Planning This includes collaborative joint supports/services, and/or treatment planning activities of the consumer, the CMHSP Program and the Health Plan regarding specialty developmental disability services, mental health services, and medical services provided by each party to the mutual consumer. - It includes identifying responsibilities to, and processes for: joint service planning meetings; sharing of assessments and background information; employing person-centered processes to develop supports/services plans; assigning supports/services coordination responsibilities; ongoing monitoring (inclusive of health status) and communication about services rendered or additional services needed. For persons with developmental disability, a critical responsibility that needs to be identified relates to the physician responsibilities. This will need to be handled on an individual basis, Model Agreement between Health Plan and CMHSP (Developmental Disabilities) C-49 Page 4 but the process must be clearly laid out for defining the respective responsibilities of the CMHSP physician and the CHPP primary physician. The two parties must establish a process for clinical staffings in order that the clinical staff of the two agencies meet on a regular basis to review the plans and status of mutual consumers. The interagency treatment/supports planning process further involves sharing of written documents and verbal reports, and discussions at joint supports/services planning meetings. (C) Emergency Services. In accordance with the definition of emergency services described in Medicaid rules, regulations, and manuals, emergency services also include those services provided to a person suffering from an acute problem in behavior or mood which requires immediate intervention. The need for the intervention may be identified by the enrollee, the enrollee's family or social unit, other agencies or referral sources, or law enforcement personnel. It is the responsibility of the Health Plan to ensure that emergency services are available 24 hours a day and 7 days a week. As part of its responsibilities to provide emergency services and mental health outpatient services, the Health Plan must make available mental health crisis services for its enrollees. This applies for all enrollees except for those who are receiving specialized behavioral health services. If the emergency is of a medical/physical nature, it is the responsibility of the Health Plan. If the emergency results from crises in the supports system of the consumer it is the responsibility of the specialty developmental disability provider. The Health Plan has the responsibility to inform all enrollees of emergency service procedures for accessing emergency services and to inform members of the designated emergency phone number through member services materials and programs. Prior approval by the Health Plan is not required. It is the responsibility of the CMHSP to provide for emergency mental health services for all enrollees receiving specialized behavioral health services including: access by telephone 24 hours a day, seven days a week. Such number shall be made available to the Health Plan to provide to all enrollees; provision for face-to-face services to persons in need of crisis evaluation, and admission screening for psychiatric inpatient admissions, intervention and disposition. (D) Pharmacy and Laboratory Services All pharmacy and laboratory services are covered by the Health Plan. This includes drugs prescribed and laboratory services ordered by the Health Plan or by the behavioral health and developmental disability providers (CMHSP). Prescriptions and Orders for Laboratory Services: Model Agreement between Health Plan and CMHSP (Developmental Disabilities) C-50 Page 5 1. The Health Plan cannot restrict prescriptions written by the developmental disability physicians as long as: a. The drug prescribed is for the treatment of the developmental disability or for any complication due to the developmental disability. b. The purchase is made from an approved Health Plan pharmacy. 2. The Health Plan cannot restrict orders for laboratory services to test for developmental disabilities or the complications due to the disability, except that the laboratory must be approved by the Health Plan. 3. The Health Plan cannot restrict orders for laboratory services to test for and monitor the medications prescribed by the developmental disability services physician, except that the laboratory must be approved by the Health Plan. 4. The Health Plan and the CMHSP must develop approval mechanisms for other laboratory and imaging services (e.g. MRI, CAT scans, X-rays, etc). Pharmacy and Laboratory Services Coordination: 1. The Health Plan and the CMHSP must develop procedures for notifying each other of prescriptions, and when deemed advisable, consultation between practitioners before prescribing medication, and sharing complete and up-to-date medication records. 2. The CMHSP in cooperation with the Health Plan is responsible to monitor and track pharmaceutical usage in order for the Health Plan to provide comprehensive data and information as required under contract with the Department of Community Health. Pharmacies and Laboratories: The Health Plan must ensure that pharmacy and laboratory services are easily accessible to the recipients of developmental disability services. Strategies to accomplish this include the location of pharmacies and laboratories in proximity to specialty service locations and/or public transportation, home delivery services, or other methods of the provision of these services. The CMHSP shall assist the Health Plan in identifying existing locations used by consumers and/or alternative delivery strategies. Drug Formulary: 1. The Health Plan drug formulary for developmental disabilities and for behavioral health must include all of the drugs currently covered for the Medicaid FFS population. 2. The Health Plan must have a process to evaluate requests to add products not included in its drug formulary. Wm. Model Agreement between Health Plan and CMHSP (Developmental Disabilities) C-51 Page 6 (E) Medical Coordination In order to coordinate the appropriate delivery of health care services to Medicaid enrollees clarity regarding the respective responsibility is necessary. Both parties will develop referral procedures and effective means of communicating the need for individual referrals. In addition, both the Health Plan and CMHSP acknowledge respective individual responsibilities as listed below: Habilitation and rehabilitation services. Habilitation services means those services designed to assist Medicaid enrollees in the development of skills and capacities they have never possessed, ( i.e., predominantly in the functioning areas of self-care and/or activities of daily living), and to maintain capacities attained for the first time. Habilitation services are the responsibility of the CMHSP. Rehabilitation services are designed to assist Medicaid enrollees in restoring those self care skills they once possessed and is the responsibility of the Health Plan. Case Management: Case management services means those services which will assist Medicaid enrollees in gaining access to needed medical, social, educational and other services. It is the expectation that Health Plans will demonstrate a commitment to assisting enrollees in managing their complex health care needs. Within the developmental disabilities specialty services system, case management includes: assessment, person-centered service plan development, linking/coordination of services, reassessment/follow-up, advocacy and monitoring of services. Some CMHSP consumers of DD services receive these case management services under a coverage entitled "supports coordination". As part of the referral procedures described above, the Health Plan and CMHSP shall both indicate the manner in which case management services will be coordinated. Health and Medical Services: A number of mutually served consumers will be jointly under the care of at least two physicians, namely the Health Plan primary health care physician and the specialty developmental disabilities physician. The treatment planning process must clearly define the respective responsibilities for these two physicians. On an individual consumer basis other health related services will need to be clarified. Such health related services include nutrition/dietary, maintenance of health and hygiene, nursing services, teaching self-administration of medications, etc. It is jointly the responsibility of the Health Plan and CMHSP to conduct utilization review for Medicaid enrollees. This is defined as the process of evaluating the necessity, appropriateness and efficiency of health care services. The information developed in this process is essential to the Quality Improvement Plans of each party. Model Agreement between Health Plan and CMHSP (Developmental Disabilities) C-52 Page 7 (F) Quality Improvement Both parties agree that a set of Quality Improvement activities to monitor the coordination of services is necessary. The Quality Improvement process will establish performance stan- dards that will be used to monitor access, coordination, outcome, and satisfaction of services. (G) Data and Reporting Requirements and Release of Information Both parties will agree to coordinate the data sharing necessary for completing reporting requirements established through their respective contracts with the Department of Community Health. Such data sharing should involve performance indicators such as: -- mental health emergency including pre-admission screening for DD Centers or AIS/MR services -- referrals to CMHSP specialized developmental disabilities services — Pharmacy and Laboratory utilization -- coordination between the QHP and the CMHSP -- Consumer/enrollee satisfaction with services and coordination. Both parties shall agree to obtain any necessary signed releases of information from the enrollee so that treatment information can be shared without impediment between the two parties to this agreement. The Mental Health Code stipulates that the holder of the mental health record may disclose information "as necessary in order for the recipient to apply for or receive benefits." (H) Grievance and Complaint Health Plans are required to establish internal processes for resolution of complaints and grievances from enrollee members. Medicaid enrollees may file a complaint or grievance on any aspect of service provided to them by the health plan or the health plan's contracted providers. CMHSPs are required to establish second opinion mechanisms and internal recipient rights processes for resolution of complaints from recipients and others. Both parties are responsible for informing the other about their grievance and complaint processes. Both parties are responsible to provide information to Medicaid enrollee members regarding the health plan's grievance and complaint processes and that of the CMHSP. (I) Dispute Resolution The parties must specify the steps that the Health Plan or CMHSP must follow to contest a decision or action by the other party related to the terms of the agreement. The process should specify the responsibilities of the parties and time frame for each step. Model Agreement between Health Plan and CMHSP (Developmental Disabilities) C-53 Page 8 The dispute resolution process should include: For administrative decisions: * Request to the other party for reconsideration of the disputed decision or action. * Appeal to the DCH regarding a disputed decision of a Health Plan, or for a disputed decision of a CMHSP. For clinical decisions: * Request to the other party for reconsideration of the disputed decision or action. * Appeal to a locally-established clinical review team comprised of Medical Directors, or their designees, from the CMHSP and the Health Plan. * Appeal to a clinical review team consisting of medical professionals representing the Department of Community Health. (5) Indemnification Both parties will agree to provisions that protect against liability in the performance of activities related to this agreement. (6) Governing Laws Both parties agree that performance under this agreement will be conducted in compliance with all federal, state, and local laws, regulations, guidelines and directives. SIGNATURE Approved as to form by local Counsel. Model Agreement between Health Plan and CMHSP (Developmental Disabilities) C-54 Page 9 ATTACHMENT 1 ELIGIBILITY CRITERIA DEVELOPMENTAL DISABILITIES SERVICE CARVE OUT Health plan members may be referred for specialized services for persons with developmental disabilities provided through Michigan Community Mental Health Services Programs (CMHSP) when the member meets one or more of the following criteria: 1. Meets the Michigan Mental Health Code definition of developmental disability; 2. Has a confirmed diagnosis of severe or profound mental retardation, or mild or moderate mental retardation in combination with cerebral palsy, physical disability, sensory impairment, or challenging behaviors; 3. Has a documented la of 70 or below; 4. Has a designation of SMI, SXI, Al or TMI established by the school system; 5. Has a documented developmental delay based on administration of a standardized developmental test, such as the Denver Developmental Screening or the Gesell Developmental Test. Additionally, the individual must have an apparent need for, or have requested, one or more of these specialized services provided through the CMHSP system: 1. Inpatient services in a State Center for Persons with Developmental Disabilities. 2. Specialized residential services. 3. Day program services. 4. Outpatient Mental Health Clinic Services when the service is habilitative and part of a plan of comprehensive supports/services. 5. Emergency DD services as needed to augment emergency services provided by the health plan. 6. Supportive services. 7. Prevention programs. 8. Testing and assessments. 9. Other services, by mutual agreement of the Health Plan and the CMHSP. Persons who are referred to the CMHSP will be screened to determine the level of need. Services will be provided according to the service priorities specified in the Michigan Mental Health Code. Some services may be limited or not available, due to funding limitations or capacity restrictions. C-55 MEDICAID MANAGED MENTAL HEALTH CARE Coordination Between Community Mental Health and Health Plans Behavioral Health Services The purpose of this attachment is to support state policy of coordination between providers of Medicaid health care services. In 1996-97, Health Plans (HMOs, Clinic Plans, Qualified Health Plans) and Community Mental Health Services Programs (CMHSPs) will be expected to develop local written agreements that delineate the areas of shared responsibilities for Medicaid recipients. The purpose of these local agreements is to define coordination and collaboration between the agencies in order to promote and protect the health of Medicaid recipients. The agreements must include the following areas of shared responsibilities: Referral Interagency Assessment and Supports/Services Planning Emergency Services Pharmacy and laboratory service coordination Medical Coordination Quality Improvement coordination Data and reporting requirements Grievance and complaint resolution Dispute Resolution Under the contracts for 1997, the Health Plans will be required to have written agreements with CMHSPs. These agreements must incorporate and address all of the items and areas listed and described in the following model agreement for specialized behavioral health services and supports. As of July 1, 1997 the Health Plans will no longer be responsible for authorizing psychiatric inpatient hospitalizations or partial hospitalization services. These responsibilities will be assumed by CMH. January 1, 1997 Model Agreement Between Health Plans and CMHSP(Behavioral Health) C-56 Page 2 Model Agreement Between HEALTH PLAN and Local Behavioral Health Contractor (Community Mental Health Service Program, CMHSP) The agreements between the Health Plan (Health Maintenance Organizations, Clinic Plans, and Qualified Health Plans) and the local behavioral health contractor (CMHSP) must incorporate and address all of the items and areas listed and described below. These standard provisions are as follows: --Legal Basis —Term of Agreement --Administration --Areas of Shared Responsibility --Referral —Interagency Assessment and Supports/Services Planning —Emergency Services —Pharmacy and laboratory service coordination --Medical Coordination —Quality Improvement coordination —Data and reporting requirements --Grievance and complaint resolution —Dispute Resolution —Indemnification —Governing Laws This agreement is made and entered into this day of ,19 by and between and (Health Plan) (CMHSP) (1) Legal Basis Whereas, PA 352 of the Public Acts of 1996 permits the Department of Community Health to increase the enrollment of Medicaid eligible persons in qualified health plans on a capitated basis; and Whereas, in order to expand enrollment the Department of Community Health has established a competitive bid process that has resulted in contracts with Health Plans that are deemed to be qualified to provide specified health care services to Medicaid enrollees; and Whereas, the majority of Medicaid covered mental health services will be provided through arrangements between the Department of Community Health and selected behavioral health providers; and Model Agreement Between Health Plans and CMHSP(Behavioral Health) C-57 Page 3 Whereas, Community Mental Health Service Programs, CMHSP, are designated as the Behavioral Health Provider under contract with the Department of Community Health and consistent with the Mental Health Code; and Whereas, Health Plans and CMHSPs should coordinate and collaborate efforts in order to promote and protect the health of Medicaid enrolled population; Now, therefore the Health Plan and the CMHSP agree as follows: (2) Term of Agreement This agreement will be effective 19_ for a period not to exceed 12/31/98. This agreement will be subject to amendment due to changes in the contracts between the Department of Community Health and the Health Plan or the contract with the Community Mental Health Services Programs. Upon signed agreement of both parties, the provisions of this agreement will be extended for a time frame consistent with the contract period of the Health Plan and the Department of Community Health. Either party may cancel the agreement upon 30 day written notice. (3) Administration and Point of Authority The Health Plan shall designate in writing to the CMHSP the person who has authority to administer this agreement. The CMHSP shall designate in writing to the Health Plan the person who has authority to administer this agreement. (4) Areas of Shared Responsibility In order to provide the most efficient and coordinated services to Medicaid enrollees, the responsibilities of the Health Plan and CMHSP will include: (A) Referral Mutually Served Consumers This refers to Health Plan members who also receive specialized CMHSP behavioral health services. Mutual consumer groups will be defined according to clinical criteria agreed upon between the individual CMHSP and Health Plan. For adults with severe and persistent mental illness and for children and adolescents with severe emotional disturbance the criteria should be based upon the combination of diagnosis, degree of disability, duration, and prior service utilization. Services to be provided by the Health Plan and by CMHSP may vary for different clinically defined groups. Model Agreement Between Health Plans and CMHSP(Behavioral Health) C-58 Page 4 Entry to CMHSP Specialized Behavioral Health Services This is the process of obtaining CMHSP approval for a Health Plan member to receive specialized behavioral health services from CMHSP. Specialized behavioral health services means those provided by a psychiatric hospital or inpatient unit of a community hospital, partial hospitalization services or those unique services of CMHSP which support persons in community environments and/or provide alternatives to, or decrease the need for psychiatric inpatient services or state facility services. These might include such services as assertive community treatment, specialized residential services, day program services, Mental Health Clinic services, psychosocial rehabilitation services, home based services, etc. Services To Be Provided (Benefit Packages and Limitations) The intent of establishing written procedures between Health Plans and CMHSP Programs is to assure service coordination and continuity of care for persons receiving services from both organizations. Therefore it is essential that the parties define the service/coverage package which will be provided by each party to mutual consumers. This must also specify any limitations on amounts of services, including but not restricted to: * emergency services * inpatient psychiatric hospital and other hospital services * outpatient mental health services * physician, especially neurological assessments and treatment, diagnostics, and orders for therapies; * pharmacy and laboratory services * therapies (physical, occupational, speech) * Mental Health Clinic Services * personal care services, including Home Help and specialized Mental Health personal care * substance abuse services * transportation to medical services & to Mental Health services (B) Interagency Assessment and Supports/Services Planning This includes collaborative joint supports/services, and/or treatment planning activities of the consumer, the CMHSP Program and the Health Plan regarding mental health services, specialty developmental disability services and medical services provided by each party to the mutual consumer. It includes identifying responsibilities to, and processes for: joint service planning meetings; sharing of assessments and background information; employing person-centered processes to develop supports/services plans; assigning supports/services coordination responsibilities; ongoing monitoring (inclusive of health status) and communication about services rendered or additional services needed. Model Agreement Between Health Plans and CMHSP(Behavioral Health) C-59 Page 5 The two parties must establish a process for clinical staffings in order that the clinical staff of the two agencies meet on a regular basis to review the plans and status of mutual consumers. The interagency treatment/supports planning process further involves sharing of written documents and verbal reports, and discussions at joint supports/services planning meetings. (C) Emergency Services. In accordance with the definition of emergency services described in Medicaid rules, regulations, and manuals, emergency services also include those services provided to a person suffering from an acute problem in behavior or mood which requires immediate intervention. The need for the intervention may be identified by the enrollee, the enrollee's family or social unit, other agencies or referral sources, or law enforcement personnel. It is the responsibility of the Health Plan to ensure that emergency services are available 24 hours a day and 7 days a week. As part of its responsibilities to provide emergency services and mental health outpatient services, the Health Plan must make available mental health crisis services for its enrollees. This applies for all enrollees except for those who are receiving specialized behavioral health services. If the emergency is of a medical/physical nature, it is the responsibility of the Health Plan. The Health Plan has the responsibility to inform all enrollees of emergency service procedures for accessing emergency services and to inform members of the designated emergency phone number through member services materials and programs. Prior approval by the Health Plan is not required. It is the responsibility of the CMHSP to provide for emergency mental health services for all enrollees receiving specialized behavioral health services including: • access by telephone 24 hours a day, seven days a week. Such number shall be made available to the Health Plan to provide to all enrollees; • provision for face-to-face services to persons in need of crisis evaluation, and admission screening for psychiatric inpatient admissions, intervention and disposition. (D) Pharmacy and Laboratory Services All pharmacy and laboratory services are covered by the Health Plan. This includes drugs prescribed and laboratory services ordered by the Health Plan or by the behavioral health and developmental disability providers (CMHSP). Prescriptions and Orders for Laboratory Services: 1. The Health Plan cannot restrict prescriptions written by the behavioral health physicians as long as: Model Agreement Between Health Plans and CMHSP(Behavioral Health) C-60 Page 6 a. The drug prescribed is for the treatment of mental illness or substance abuse and any side effects of psychopharmacological agents. b. The purchase is made from an approved Health Plan pharmacy. 2. The Health Plan cannot restrict orders for laboratory services to test for and monitor the medications prescribed by the behavioral health physician, except that the laboratory must be approved by the Health Plan. 3. The Health Plan and the CMHSP must develop approval mechanisms for other laboratory and imaging services (e.g. MRI, CAT scans, X-rays, etc). Coordination: 1. The Health Plan and the CMHSP must develop procedures for notifying each other of prescriptions, and when deemed advisable, consultation between practitioners before prescribing medication, and sharing complete and up-to-date medication records. 2. The CMHSP in cooperation with the Health Plan is responsible to monitor and track pharmaceutical usage in order for the Health Plan to provide comprehensive data and information as required under contract with the Department of Community Health. Pharmacies and Laboratories: The Health Plan must ensure that pharmacy and laboratory services are easily accessible to the recipients of the specialized behavioral health services. Strategies to accomplish this include the location of pharmacies and laboratories in proximity to specialty service locations and/or public transportation, home delivery services, or other methods of the provision of these services. The CMHSP shall assist the Health Plan in identifying existing locations used by consumers and/or alternative delivery strategies. Dru_g Formulary: 1. The Health Plan drug formulary for developmental disabilities and for behavioral health must include all of the drugs currently covered for the Medicaid FFS population. 2. The Health Plan must have a process to evaluate requests to add products not included in its drug formulary. (E) Medical Coordination In order to coordinate the appropriate delivery of health care services to Medicaid enrollees clarity regarding the respective responsibility is necessary. Both parties will develop referral procedures and effective means of communicating the need for individual referrals. Model Agreement Between Health Plans and CMHSP(Behavioral Health) C-61 Page 7 It is the responsibility of Health Plans to provide or arrange for a limited number of outpatient visits (20 visits). The Health Plan may contract with CMHSP to provide this benefit. Payment for these services are the responsibility of the Health Plan. It is the responsibility of the CMHSP to provide or arrange for all inpatient (including entry and exit from state facilities) services and specialty mental health services. Payment for these services will be the responsibility of the CMHSP and Department of Community Health. Health and Medical Services: A number of mutually served consumers will be jointly under the care of at least two physicians, namely the Health Plan primary health care physician and the specialty behavioral health physician. The treatment planning process must clearly define the respective responsibilities for these two physicians. On an individual consumer basis other health related services will need to be clarified. Such health related services include nutrition/dietary, maintenance of health and hygiene, nursing services, teaching self- administration of medications, etc. It is jointly the responsibility of the Health Plan and CMHSP to conduct utilization review for Medicaid enrollees. This is defined as the process of evaluating the necessity, appropriateness and efficiency of health care services. The information developed in this process is essential to the Quality Improvement Plans of each party. (F) Quality Improvement Both parties agree that a set of Quality Improvement activities to monitor the coordination of services is necessary. The Quality Improvement process will establish performance standards that will be used to monitor access, coordination, outcome, and satisfaction of services. (G) Data and Reporting Requirements and Release of Information Both parties will agree to coordinate the data sharing necessary for completing reporting requirements established through their respective contracts with the Department of Community Health. Such data sharing should involve performance indicators such as: -- mental health emergency services including pre-admission screening for psychiatric inpatient services -- inpatient utilization -- referrals to CMHSP specialized mental health services -- Pharmacy and Laboratory utilization -- coordination between the Health Plan and the CMHSP — Consumer/enrollee satisfaction with services and coordination. Both parties shall agree to obtain any necessary signed releases of information from the enrollee so that treatment information can be shared without impediment between the two parties to this agreement. The Mental Health Code stipulates that the holder of the mental health record may disclose information "as necessary in order for the recipient to apply for or receive benefits". Model Agreement Between Health Plans and CMHSP(Behavioral Health) C-62 Page 8 (H) Grievance and Complaint Health Plans are required to establish internal processes for resolution of complaints and grievances from enrollee members. Medicaid enrollees may file a complaint or grievance on any aspect of service provided to them by the health plan or the health plan's contracted providers. CMHSPs are required to establish second opinion mechanisms and internal recipient rights processes for resolution of complaints from recipients and others. Both parties are responsible for informing the other about their consumer grievance and complaint process. Both parties are responsible to provide information to Medicaid enrollee members regarding the health plan's grievance and complaint process and that of the CMHSP. (I) Dispute Resolution The parties must specify the steps that the Health Plan or CMHSP must follow to contest a decision or action by the other party related to the terms of the agreement. The process should specify the responsibilities of the parties and time frame for each step. The dispute resolution process should include: For administrative decisions: * Request to the other party for reconsideration of the disputed decision or action. * Appeal to the DCH regarding a disputed decision of a Health Plan, or for a disputed decision of a CMHSP. For clinical decisions: * Request to the other party for reconsideration of the disputed decision or action. * Appeal to a locally-established clinical review team comprised of Medical Directors, or their designees, from the CMHSP and the Health Plan. * Appeal to a clinical review team consisting of medical professionals representing the Department of Community Health. (5) Indemnification Both parties will agree to provisions that protect against liability in the performance of activities related to this agreement. (6) Governing Laws Both parties agree that performance under this agreement will be conducted in compliance with all federal, state, and local laws, regulations, guidelines and directives. SIGNATURE Approved as to form by local Counsel. MANAGED MENTAL HEALTH SERVICES PROGRAM UTILIZATION MANAGEMENT CRITERIA LEVEL OF CARE DETERMINATION GUIDELINES TABLE OF CONTENTS INTRODUCTION 1 INPATIENT ADMISSION CERTIFICATION CRITERIA: ADULTS 3 INPATIENT ADMISSION CERTIFICATION CRITERIA: CHILDREN/ADOLESCENTS 6 INPATIENT PSYCHIATRIC CARE CONTINUING STAY CERTIFICATION 9 INTENSIVE CRISIS RESIDENTIAL SERVICES ADMISSION CRITERIA: ADULTS 11 INTENSIVE CRISIS RESIDENTIAL SERVICES ADMISSION CRITERIA: CHILDREN/ADOLESCENTS 13 PARTIAL HOSPITALIZATION ADMISSION CERTIFICATION CRITERIA: ADULTS 15 PARTIAL HOSPITALIZATION ADMISSION CRITERIA: CHILDREN/ADOLESCENTS 17 PARTIAL HOSPITALIZATION CONTINUING STAY CERTIFICATION 20 INTENSIVE CRISIS STABIUZATION SERVICES CRITERIA: ADULTS, CHILDREN/ADOLESCENTS 21 C-63 C-e4 Utilization Management Criteria - Level of Care Determination Guidelines Page 1 Introduction The DMH-CMH Utilization Management Criteria - Level of Care Determination Guidelines are protocols designed to assist clinicians in review activities related to the utilization of various levels of care. They reflect the application of certain principles either stated or implied in the mental health code and administrative rules, and they embody utilization management concepts prevalent in contemporary clinical practice. The code and the rules accentuate the idea of least restrictive environment, and they provide a definition of mental illness, a functionally based concept of impairment and the notion of risk estimation. Utilization management standards combine some of these same ideas into criteria of severity of illness and intensity of service. The subtle differences among the criteria for the various levels of care contained in these Guidelines reflect the interplay of three interacting and often overlapping concepts: symptom acuity, functional impairments, and risk potential (clinical stability). An appreciation of these variables is crucial for developing an estimation of the severity of a given illness and for determining the required care setting or service intensity necessary to safely and appropriately treat the particular mental disorder. These protocols th ngt constitute a standard of practice, nor are they a substitute for thorough assessment and clinical judgment. Rather, the Guidelines are part of a utilization management system intended to monitor the appropriateness of care received by Medicaid recipients. Medicaid coverage for psychiatric care and services requires that treatment be medically necessary. Medically necessary services are generally considered to be those that: a) are adequate and essential for evaluation and/or treatment of an illness or condition, as defined by standard diagnostic nomenclature (DSM-IV, (CD-10); b) can reasonably be expected to improve an individual's condition or level of functioning; c) are in keeping with national standards of mental health practice; and d) are provided at the appropriate, least restrictive level of care. For the purpose of constructing these guidelines, the subsequent definitions were used, and are reflected in the level of care-utilization review criteria that follows: Mental Illness (adults): A substantial disorder of thought or mood that significantly impairs judgment, behavior, capacity to recognize reality or the ability to cope with the ordinary demands of life. The specific illness should be reflected in a validated, principal, DSM-IV or ICD-10 diagnosis (not including V Codes). Mental Illness (children/adolescents): Either a substantial disorder of thought or mood that significantly impairs judgment, behavior, capacity to recognize reality or the ability to cope with the ordinary demands of life, or an emotional condition characterized by significantly impaired personality development, individual adjustment, social adjustment, or emotional growth, which is demonstrated in behavior symptomatic of that impairment. Utilization Management Criteria - Level of Care Determination Guidelines 0-65 Page 2 The specific illness should be reflected in a validated, principal, DSM-IV or ICD-10 diagnosis (not including V Codes). Functional Impairment: Refers to the degree to which an individual is unable, or has difficulty attending to, one or more self-care needs, basic physical needs (nutrition, shelter, etc.), to familial or social role expectations, and/or to vocational or educational responsibilities, due to impaired judgment, cognition, affective regulation, or impulse control, related to a mental disorder. Risk Estimation/Clinical Stability: The degree to which an individual is at risk of injury due to self/other harm inclinations, reckless activities (not arising from antisocial behavior or related traits), loss of ability to perform activities of daily living (due to severely impaired judgment, impulse control, cognition or affective regulation) or due to lack of necessary skills or environmental supports. Severity of Illness: Refers to the nature and severity of the signs, symptoms, functional impairments and risk potential related to the client's disorder. It is assumed that as the severity of illness increases, the level of care needed to treat the recipient will also intensify. Intensity of Services: The setting of care, usually corresponding to the types and frequency of needed services and supports and to the degree of restrictiveness necessary to safely and effectively treat the recipient. Least Restrictive Environment: The least intensive/restrictive setting of care sufficient to effectively, safely and appropriately treat the client's condition and to achieve the purposes of treatment and/or rehabilitation. These guidelines are intended to assist reviewers, practitioners and facilities in determining the appropriate level of care for Medicaid recipients needing active treatment for a mental illness. It is recognized that some recipients will have other disorders (e.g., developmental disabilities or substance abuse) that co-exist with the psychiatric disturbance. In regard to developmental disabilities, if a person presents with a primary diagnosis of developmental disability, but exhibits symptoms of a significant, concomitant mental illness, the mental illness will take precedence for purposes of care and placement decisions. For individuals who have a mental illness and a co-existing substance abuse disorder, it may sometimes be difficult to determine whether symptoms exhibited are due to the mental illness or the substance abuse disorder and to make informed level of care placement decisions. A recipient with such a dual diagnosis may require substance abuse detoxification prior to assessment for mental health level of care placement. Such detoxification may occur at various sites (including psychiatric inpatient facilities) but, in any case, such services cannot be authorized as psychiatric care under these placement guidelines. These services should be managed and authorized according to existing Medicaid substance abuse guidelines. Utilization Management Criteria - Level of Care Determination Guidelines C-66 Page 3 INPATIENT ADMISSION CERTIFICATION CRITERIA: ADULTS GENERAL JUSTIFICATION Inpatient psychiatric care may be used to treat a mentally ill person who requires care in a 24- hour medically structured and supervised facility. The Severity of Illness (Sp/Intensity of Service (IS) criteria for admission are based upon the assumption that the recipient is displaying signs and symptoms of a serious psychiatric disorder, demonstrating functional impairments, and manifesting a level of clinical instability (risk) that, either individually or collectively, are of such severity that treatment in an alternative setting would be unsafe or ineffective, and that the recipient has the psychological and cognitive capacity to respond to the inpatient program. Medicaid coverage is dependent upon active treatment being provided at the medically necessary level of care, and the expectation that such treatment will reasonably result in improvement to the recipient's condition. CRITERIA - Must meet a three A. Diagnosis: The recipient must be suffering from a mental illness, reflected in a primary, validated, DSM-IV Axis I, or ICD-10 Diagnosis (not including V Codes). B. Severity of Illness (signs, symptoms, functional impairments and risk potential) At least one of the following manifestations is present: 1. severe psychiatric signs and symptoms: 2. serious disruptions of self-care, inability to attend to basic physical needs, grave and disabling impairments in interpersonal functioning, and/or severe deterioration in educational/ occupational role performance 3. harm to self 4. harm to others 5. drug/medication complications and/or significant co-existing general medical condition which needs to be simultaneously addressed along with the psychiatric illness and which cannot be carried out at a less intensive level of care. 1. Severe Psychiatric Signs and Symptoms • Psychiatric symptoms - features of intense cognitive/perceptual/affective disturbance (hallucinations, delusions, extreme agitation, profound depression) - severe enough to cause seriously disordered and/or bizarre behavior (e.g., catatonia, mania, incoherence) or prominent psychomotor retardation, resulting in extensive interference with activities of daily living, so that the person cannot function at a lower level of care. Utilization Management Criteria - Level of Care Determination Guidelines C-67 Page 4 • Disorientation, seriously impaired reality testing, defective judgment, impulse control problems and/or memory impairment severe enough to endanger the welfare of the person and/or others. • A severe, life-threatening psychiatric syndrome or an atypical or unusually complex psychiatric condition exists that has failed, or is deemed unlikely, to respond to less intensive levels of care, and has resulted in substantial current dysfunction. 2. Disruptions of Self Care and Independent Functioning • The person is unable to attend to basic self-care tasks and/or to maintain adequate nutrition, shelter, or other essentials of daily living due to psychiatric disorder. • There is evidence of grave impairment in interpersonal functioning and/or extreme deterioration in the person's ability to meet current educational/occupational role performance expectations. 3. Harm to Self • Suicide: Attempt or ideation is considered serious by the intentionality, degree of lethality, extent of hopelessness, degree of impulsivity, level of impairment (current intoxication, judgment, psychological symptoms), history of prior attempts, and/or existence of a workable plan. • Self-Mutilation and/or Reckless Endangerment: There is evidence of current behavior, or recent history. There is a verbalized threat of a need or willingness to self-mutilate, or to become involved in other high-risk behaviors; and intent, impulsivity, plan and judgment would suggest an inability to maintain control over these ideations. • Other Self-Injurious Activity: The person has a recent history of drug ingestion with a strong suspicion of overdose. The person may not need detoxification but could require treatment of a substance induced psychiatric disorder. 4. Harm to Others • Serious assaultive behavior has occurred, and there is a risk of escalation or repetition of this behavior in the near future. • There is expressed intention to harm others and a plan and/or means to carry it out, and the level of impulse control is non-existent or impaired (due to psychotic symptoms, especially command or verbal hallucinations, intoxication, judgment, or psychological symptoms, such as persecutory delusions and paranoid ideation). • There has been significant destructive behavior toward property which endangers others. Utilization Management Criteria - Level of Care Determination Guidelines C-68 Page 5 5. Drug/Medication Complications or Co-Existing General Medical Condition Requiring Care • The person has experienced severe side effects of atypical complexity from using therapeutic psychotropic medications. • The person has a known history of psychiatric disorder that requires psychotropic medication for stabilization of the condition, and the adjustment or re-initiation of medications following discontinued use requires close and continuous observation and monitoring, and this cannot be accomplished at a lower level of care due to the recipient's condition or to the nature of the procedures involved. • There are concurrent significant physical symptoms or medical disorders which necessitate evaluation, intensive monitoring and/or treatment during medically necessary psychiatric hospitalization, and the co-existing general medical condition would complicate or interfere with treatment of the psychiatric disorder at a less intensive level of care. Special Consideration: Concomitant Substance Abuse • The underlying psychiatric diagnosis must be the primary cause of the recipient's current symptoms or represent the reason observation and treatment is necessary in the hospital setting. • Symptoms arising from a current episode of substance abuse should be managed according to substance abuse treatment guidelines before the need for psychiatric hospital bed admission is warranted. Utilization Management Criteria - Level of Care Determination Guidelines C-69 Page 6 C. Intensity of Service The person meets the intensity of service requirements if inpatient services are considered medical necessary and if the person requires at least one of the following: 1 Close and continuous skilled medical observation and supervision are necessary to make significant changes in psychotropic medications. 2. Close and continuous skilled medical observation is necessary due to otherwise unmanageable side effects of psychotropic medications. 3. Continuous observation and control of behavior (e.g., isolation, restraint, closed unit, suicidal/homicidal precautions) is needed to protect the recipient, others, and/or property, or to contain the recipient so that treatment may occur. 4. A comprehensive multi-modal therapy plan is needed, requiring close medical supervision and coordination, due to its complexity and/or the severity of the recipient's signs and symptoms. • C-70 Utilization Management Criteria - Level of Care Determination Guidelines Page 7 INPATIENT ADMISSION CERTIFICATION CRITERIA: CHILDREN AND ADOLESCENTS THROUGH AGE 21 GENERAL JUSTIFICATION Inpatient psychiatric care may be used to treat a mentally ill/emotionally disturbed child or adolescent who requires care in a 24-hour medically structured and supervised facility. The Severity of Illness (SO/Intensity of Service (IS) criteria for admission are based on the assumption that the recipient is displaying signs and symptoms of a serious psychiatric disorder, demonstrating functional impairments and manifesting a level of clinical instability (risk) that are, either individually or collectively, of such severity that treatment in an alternative setting would be unsafe or ineffective, and that the recipient has the psychological and cognitive capacity to respond to the inpatient program. If inpatient admission is indicated, the assessment should also determine parental commitment to active participation in treatment. Medicaid coverage is dependent upon active treatment being provided at the medically necessary level of care, and the expectation that such treatment will reasonably result in improvement to the recipient's condition. CRITERIA - Must meet a three A. Diagnosis: The recipient must be suffering from a mental illness, reflected in a primary, validated, DSM-IV Axis I, or ICD-10 Diagnosis (not including V Codes). B. Severity of Illness (signs, symptoms, functional impairments and risk potential) At least one of the following manifestations is present: 1. severe psychiatric signs and symptoms; 2. serious disruptions of self-care and/or severely and pervasively impaired personal adjustment, demonstrated in behavior or dysfunction symptomatic of that impairment 3. harm to self 4. harm to others 5. drug/medication complications and/or significant co-existing general medical condition which needs to be simultaneously addressed along with the psychiatric illness and which cannot be carried out at a less intensive level of care 1. Severe Psychiatric Signs and Symptoms • Psychiatric symptoms - features of intense cognitive/perceptual/affective disturbance (hallucinations, delusions, extreme agitation, profound depression) - severe enough to cause disordered and/or bizarre behavior (e.g., catatonia, mania, incoherence) or prominent psychomotor retardation, resulting in extensive interference with activities of daily living, so that the person cannot function at a lower level of care. Utilization Management Criteria - Level of Care Determination Guidelines C-71 Page 8 • Disorientation, impaired reality testing, defective judgment, impulse control problems and/or memory impairment severe enough to endanger the welfare of the person and/or others. • Severe anxiety, phobic symptoms or agitation, or ruminative/ obsessive behavior that has failed, or is deemed unlikely, to respond to less intensive levels of care and has resulted in substantial current dysfunction. 2. Disruption of Self Care/Support or Severely Impaired Personal Adjustment • Recipient is unable to maintain adequate nutrition or self care due to a severe psychiatric disorder. • The recipient exhibits significant inability to attend to age appropriate responsibilities, and there has been a serious deterioration/impairment of interpersonal, familial, and/or educational functioning due to an acute psychiatric disorder or severe developmental disturbance. 3. Harm to Self • A suicide attempt has been made which is serious by degree of lethal intent, hopelessness, impulsivity. • There is a specific plan to harm self with clear intent and/or lethal potential. • There is self-harm ideation or threats without a plan which are considered serious due to impulsivity, current impairment or a history of prior attempts. • There is current behavior or recent history of self-mutilation, severe impulsivity, significant risk taking or other self-endangering behavior. • There is a verbalized threat of a need or willingness to self-mutilate, or to become involved in other high-risk behaviors; and intent, impulsivity, plan and judgment would suggest an inability to maintain control over these ideations. • There is a recent history of drug ingestion with a strong suspicion of intentional overdose. The person may not need detoxification but could require treatment of a substance induced psychiatric disorder. 4. Harm to Others • Serious assaultive behavior has occurred and there is a clear risk of escalation or repetition of this behavior in the near future. • There is expressed intention to harm others and a plan and means to carry it out; the level of impulse control is non-existent or impaired. Utilization Management Criteria - Level of Care Determination Guidelines C-72 Page 9 • There has been significant destructive behavior toward property which endangers others, such as setting fires. 5. Drug/Medication Complications or Co-Existing General Medical Condition Requiring Care • The person has experienced severe side effects of atypical complexity from using therapeutic psychotropic medications. • The person has a known history of psychiatric disorder that requires psychotropic medication for stabilization of the condition, and the adjustment or re-initiation of medications following discontinued use requires close and continuous observation and monitoring, and this cannot be accomplished at a lower level of care due to the recipient's condition or to the nature of the procedures involved. • There are concurrent significant physical symptoms or medical disorders which necessitate evaluation, intensive monitoring and/or treatment during medically necessary psychiatric hospitalization, and the co-existing general medical condition would complicate or interfere with treatment of the psychiatric disorder at a less intensive level of care. Special Consideration: Concomitant Substance Abuse • The underlying psychiatric diagnosis must be the primary cause of the recipient's current symptoms or represent the reason observation and treatment is necessary in the hospital setting. • Symptoms arising from a current episode of substance abuse should be managed according to substance abuse treatment guidelines before the need for psychiatric hospital bed admission is warranted. C. Intensity of Service The person meets the intensity of service requirements if inpatient services are considered medical necessary and if the person requires at least one of the following: 1. Close and continuous skilled medical observation and supervision are necessary to make significant changes in psychotropic medications. 2. Close and continuous skilled medical observation are needed due to otherwise unmanageable side effects of psychotropic medications. 3. Continuous observation and control of behavior (e.g., isolation, restraint, closed unit, suicidal/homicidal precautions) to protect the recipient, others, and/or property, or to contain the recipient so that treatment may occur. 4. A comprehensive multi-modal therapy plan is needed, requiring close medical supervision and coordination, due to its complexity and/or the severity of the recipient's signs and symptoms. C-73 Utilization Management Criteria - Level of Care Determination Guidelines Page 10 AUTHORIZATION OF INPATIENT PSYCHIATRIC CARE CONTINUED STAY FOR ADULTS, ADOLESCENTS AND CHILDREN RECERTIFICATION RATIONALE After a recipient has been certified for admission to an inpatient psychiatric setting, services will be reviewed at regular intervals to assess the current status of the treatment process and to determine the continuing need for treatment in an inpatient setting. Treatment within an inpatient psychiatric setting is directed at stabilization of incapacitating signs or symptoms, amelioration of severely disabling functional impairment, arrest of potentially life threatening self/other harm inclinations, management of adverse biologic reactions to treatment and/or close monitoring of complicating medical conditions. The continuing stay recertification process is designed to assess the efficacy of the treatment regime in addressing these concerns, and to determine whether the inpatient setting remains the most appropriate, least restrictive, level of care for treatment of the patient's problems and dysfunctions. Continued stay in an inpatient setting may be authorized when signs and symptoms, behaviors, impairment, risk of harm inclinations or biologic/medical conditions, similar to those which justified the patient's admission certification, remain present, and continue to be of such a nature and severity that inpatient level of care is still medically necessary. It is anticipated that in those reviews which fall near the end of an episode of active illness, the problems and dysfunction will have stabilized or diminished. Discharge planning must begin at the onset of treatment in the inpatient unit. Discharge criteria and aftercare planning are documented in the recipient's record. Payment cannot be authorized for continued stays that are due solely to placement problems or the unavailability of aftercare services. CRITERIA - Must meet a three. A. Diagnosis: The recipient has a mental disorder validated by classification in the current edition of the DSM or ICD(excluding V codes) which remains the principal diagnosis for purposes of care during the period under review. B. Severity of Illness: At least one of the following manifestations is present: 1. Persistence/intensification of signs/symptoms, impairments, harm inclinations or biologic/medication complications which necessitated admission to this level of care, and which cannot currently be addressed at a lower level of care; 2. continued severe disturbance of cognition, perception, affect, memory, behavior or judgment; 3. continued gravely disabling or incapacitating functional impairments or severely and pervasively impaired personal adjustment; 4. continued significant self/other harm risk; C-74 Utilization Management Criteria - Level of Care Determination Guidelines Page 11 5. use of psychotropic medication at dosage levels necessitating medical supervision, dosage titration of medications requiring skilled observation, or adverse biologic reactions requiring close and continuous observation and monitoring; 6. Emergence of new signs/symptoms, impairments, harm inclinations or medication complications, meeting admission criteria. C. Intensity of Service Must meet All of the following: 1. The recipient requires close observation and medical supervision due to the severity of signs and symptoms, in order to control risk behaviors or inclinations, to assure basic needs are met, and/or to manage biologic/medical complications. 2. The recipient is receiving timely, intensive treatment delivered according to an individualized treatment plan. 3. Active treatment is directed toward stabilizing or diminishing those symptoms, impairment, risk of harm, or biologic/medical complications which necessitated admission to inpatient care. 4. The recipient is making progress towards realistic, specific treatment goals as evidenced by a measurable reduction in sign/symptoms, impairment, risk of harm, or biologic/medical complications; or if no progress has been made within an expected time frame based on the specific prescribed treatment , there has been a major , modification of the treatment plan/therapeutic program, and there is a reasonable expectation of a positive response to treatment for this episode of illness. 5. Discharge criteria are established and aftercare planning and implementation are ongoing. C-75 Utilization Management Criteria - Level of Care Determination Guidelines Page 12 INTENSIVE CRISIS RESIDENTIAL SERVICES ADMISSION CRITERIA: ADULTS GENERAL JUSTIFICATION Intensive crisis residential services may be used to treat a mentally ill person who requires short-term care in a structured, supervised and licensed residential facility as an alternative to inpatient care. Individuals utilizing such facilities are assumed to be experiencing an acute psychiatric crisis, or to be in need of an interim program in order to shorten the length of stay of psychiatric inpatient episode. The Severity of Illness (SO/Intensity of Service (IS) criteria for admission presume that while the individual generally meets the basic criteria for inpatient care (i.e., displaying significant signs and symptoms of a psychiatric disorder, demonstrating serious functional impairments, some level of risk) he/she is not (at the time of admission) exhibiting as severe a degree of clinical instability (not at imminent risk of self/other harm) as those persons who require inpatient care, nor are there serious medication or medical complications which would necessitate treatment in a medical facility. Thus, where available, crisis residential services may be a safe and appropriate alternative for persons who meet the SI/IS criteria for this level of care. Medicaid coverage is dependent upon active treatment being provided at the medically necessary level of care, and the expectation that such treatment will reasonably result in improvement to the recipient's condition. CRITERIA - Must meet all three A. Diagnosis: The recipient must be suffering from a mental illness, reflected in a primary, validated, DSM-IV or ICD-10 Diagnosis (not including V Codes) B. Severity of Illness (signs, symptoms, functional impairments and risk potential) At least one of the following manifestations are present: 1. serious psychiatric signs and symptoms (psychotic or non-psychotic clinical characteristics which suggest a substantial pathological condition) 2. disruptions of self-care, limited ability to attend to basic physical needs (nutrition, shelter, etc.), seriously impaired interpersonal functioning, and/or significantly diminished capacity to meet educationaVoccupational role performance expectations 3. danger to self 4. danger to others • 5. drug/medication regimen compliance problems 1. Psychiatric Signs and Symptoms • A substantial disturbance of thought processes, perception, affect, memory or consciousness (due to a mental illness) exists and is severe enough to cause disordered/bizarre behavior, diminished impulse control, significantly flawed C-76 Utilization Management Criteria - Level of Care Determination Guidelines Page 13 judgment, moderate psychomotor acceleration or retardation, impaired capacity to recognize reality and/or impairments in activities of daily living. The disordered/bizarre behavior or level of agitation are not so severe or extreme as to require frequent restraints or to pose a danger to others receiving services at the residence. 2. Disruptions of Self Care and Independent Functioning • The persons has insufficient capability to adequately attend to basic self-care tasks and/or to maintain adequate nutrition, shelter, or other essentials of daily living, due to a psychiatric disorder. • The person's interpersonal functioning is seriously impaired or dysfunctional, necessitating temporary separation from the natural support system and living arrangement. • The person's is acutely incapacitated in educational/occupational role performance due to an active psychiatric disorder. 3. Danger to Self • There is some danger to self, reflected in self-harm ideations with or without a plan, recent gestures with low lethality/intent, or minor, non-severe, self-injurious behavior. • There are intermittent expressions/verbalizations of self-harm inclinations, thoughts of self-mutilation, passive wishes to die, but no persistent or unrelenting self-harm preoccupations, and no recent significant physical actions (deliberate or reckless endangerment behavior) involving actual, direct, serious harm to the self. • There may have been recent significant self-harm actions, but these inclinations/behaviors are now clearly under control, and the individual is not considered to be at imminent or serious risk if monitored in a 24 hour program with adequate supervision and supports. 4. Danger to Others • The person has expressed a wish to harm others, but has not made any plans or acquired the means to carry this out, and there is evidence of some impulse control and reality orientation. • The person may have threatened others verbally, but there have been no assaultive actions, no preparation for such actions, and there is nothing in the person's recent behavior to suggest these threats will be carried out. • There may have been minor destructive behavior toward property that has not materially endangered others. Utilization Management Criteria - Level of Care Determination Guidelines 0-77 Page 14 5. Drug/Medication Compliance • Stabilization of symptoms related to the psychiatric crisis requires adherence to a medication regimen, and initial compliance cannot be reliably assured (due to impaired cognition, consciousness, memory or judgment) without recurrent monitoring and supervision. C. Intensity of Service The person meets the intensity of service requirements crisis residential services are considered medically necessary and the person requires at least one of the following: 1. The recipient requires a highly structured, supervised care setting to prevent elevation of symptom acuity, to recover functional living skills, and to strengthen internal coping resources. 2. Consistent observation and supervision of behavior is needed to compensate for impaired reality testing, temporarily deficient internal controls, and/or faulty self- preservation inclinations. 3. The recipient has reached a level of clinical stability (diminished risk) obviating the need for restrictive inpatient care, but continues to requires a structured and supervised 24 hour program to consolidate inpatient progress. 4. Frequent monitoring of medication regimen and response is necessary and compliance is doubtful without consistent supervision and support. 5. The recipient needs to be temporarily separated from his/her natural environment, current living situation and/or support systems due to severely impaired interpersonal functioning and the risk of further deterioration of their condition and of support circumstances if an alternative setting is not utilized. 6. A concentrated, comprehensive, intensive program of treatments, services and supports is indicated by the complexity and/or the severity of the recipient's signs and symptoms. C-78 Utilization Management Criteria - Level of Care Determination Guidelines Page 15 INTENSIVE CRISIS RESIDENTIAL SERVICES ADMISSION CRITERIA FOR CHILDREN AND ADOLESCENTS GENERAL JUSTIFICATION Intensive crisis residential services may be used to treat a mentally ill child or adolescent who requires short-term care in a structured, supervised and licensed residential facility as an alternative to inpatient care. Individuals utilizing such facilities are assumed to be experiencing an acute psychiatric crisis, or to be in need of an interim program in order to shorten the length of stay of psychiatric inpatient episode. The Severity of Illness (SO/Intensity of Service (IS) criteria for admission presume that while the individual generally meets the basic criteria for inpatient care (i.e., displaying significant signs and symptoms of a psychiatric disorder, demonstrating serious functional impairments, some level of risk) he/she is ragt (at the time of admission) exhibiting as severe a degree of clinical instability (not at imminent risk of self/other harm) as those persons who require inpatient care, nor are there serious medication or medical complications which would necessitate treatment in a medical facility. Thus, where available, crisis residential services may be a safe and appropriate alternative for children or adolescents who meet the SI/IS criteria for this level of care. Medicaid coverage is dependent upon active treatment being provided at the medically necessary level of care, and the expectation that such treatment will reasonably result in improvement to the recipient's condition. CRITERIA - Must meet a three A. Diagnosis: The recipient must be suffering from a mental illness, reflected in a primary, validated, DSM-IV or ICD-10 Diagnosis (not including V Codes). B. Severity of Illness (signs, symptoms, functional impairments and risk potential) At least one of the following manifestations are present: 1. serious psychiatric signs and symptoms (psychotic or non-psychotic clinical characteristics which suggest a substantial pathological condition) 2. disruptions of self-care, significantly impaired role performance, seriously dysfunctional interpersonal interactions 3. danger to self 4. danger to others 5. drug/medication regimen compliance problems 1. Signs and Symptoms • A substantial disturbance of thought processes, perception, affect, memory, consciousness, or behavior (due to a mental illness) exists and is severe enough to cause disordered/bizarre conduct, diminished impulse control, seriously flawed Utilization Management Criteria - Level of Care Determination Guidelines Page 16 judgment, moderate psychomotor agitation or retardation, extreme fears/phobias, formidable obsessions/compulsions, impaired capacity to recognize reality and/or impairments in activities of daily living. The disordered/bizarre conduct or activity and/or the level of agitation are not so severe, extreme or unstable so as to require frequent restraints or to pose a danger to others who are receiving services at the crisis residential facility. 2. Disruptions of Self Care and Independent Functioning • The child/adolescent is unable or unwilling to fully attend to basic self-care tasks or to cooperate in the provision of basic physical needs. • There is an acute psychiatric condition or severe developmental disturbance which significantly impairs social, interpersonal, familial and/or educational functioning, and requires periodic temporary separation from the natural support system and living arrangement to prevent further deterioration of these relationships and supports. 3. Danger to Self • There is some danger to self, reflected in self-harm ideations with or without a plan, recent gestures with low lethality/intent, or minor, non-severe, self-injurious behavior. • There are intermittent expressions/verbalizations of self-harm inclinations, thoughts of self-mutilation, passive wishes to die, but no persistent or unrelenting self-harm preoccupations, and no recent significant physical actions (deliberate or reckless endangerment behavior) involving actual, direct, serious harm to the self. • There may have been recent significant self-harm actions, but these inclinations/behaviors are now clearly under control, and the individual is = considered to be at imminent or serious risk if monitored in a 24 hour program with adequate supervision and supports. 4. Danger to Others • The child/adolescent has expressed a wish to harm others, but has not made any plans or acquired the means to carry this out, and there is evidence of some impulse control and reality orientation. • The child/adolescent may have threatened others verbally, but there have been no significant assaultive actions, no preparation for such actions, and there is nothing in the child/adolescent's recent behavior to suggest these threats will be carried out. • There may have been minor destructive behavior toward property that has not materially endangered others. C-79 Utilization Management Criteria - Level of Care Determination Guidelines C-80 Page 17 • There is no chronic or recent history of violence, fire-setting or sexual offenses. 5. Drug/Medication Compliance • Stabilization of symptoms related to the psychiatric crisis requires adherence to a medication regimen, and compliance cannot be reliably assured by either the child/adolescent or their natural support system without an initial period of recurrent monitoring and supervision. C. Intensity of Service The person meets the intensity of service requirements crisis residential services are considered medically necessary and the person requires at least one of the following: 1. The recipient requires a highly structured, supervised care setting to prevent elevation of symptom acuity, to recover age-appropriate living skills, and to strengthen internal coping resources. 2. Consistent observation and supervision of behavior is needed to compensate for impaired reality testing, temporarily deficient internal controls, and/or faulty self- preservation inclinations. 3. The recipient no longer needs restrictive inpatient care, but continues to need a 24 hour, structured and supervised living arrangement and treatment program to consolidate inpatient progress, prior to returning to their natural environment. 4. Frequent monitoring of medication regimen and response is necessary and compliance is doubtful without consistent supervision and support. 5. The recipient needs to be temporarily separated from his/her natural environment, current living situation and/or support systems due to severely impaired interpersonal functioning and the risk of further deterioration of his/her condition and of support circumstances if an alternative setting is not utilized. 6. A concentrated, comprehensive, intensive program of treatments, services and supports is indicated by the complexity and/or the severity of the recipient's signs and symptoms. Utilization Management Criteria - Level of Care Determination Guidelines C-81 Page 18 PARTIAL HOSPITALIZATION ADMISSION CERTIFICATION CRITERIA: ADULTS GENERAL JUSTIFICATION Partial hospitalization services may be used to treat a mentally ill person who requires intensive, highly coordinated, multi-modal ambulatory care with active psychiatric supervision. Treatment, services and supports are provided for six or more hours per day, five days a week, in a licensed setting. The use of partial hospitalization as a setting of care presumes that the recipient does not currently need treatment in a 24 hour protective environment. Conversely, the use of partial hospitalization implies that routine outpatient treatment is of insufficient intensity to meet the recipient's present treatment needs. The Severity of Illness (SO/Intensity of Service (IS) criteria for admission assume that the recipient is displaying signs and symptoms of a serious psychiatric disorder, demonstrating significant functional impairments in either self-care, daily living skill, interpersonal/social and/or educational/ vocational domains, and is exhibiting some evidence of clinical instability. However, the level of symptom acuity, extent of functional impairments and/or the estimation of risk (clinical instability) do not justify or necessitate treatment at a more restrictive level of care. Medicaid coverage is dependent upon active treatment being provided at the medically necessary level of care, and the expectation that such treatment will reasonably result in improvement to the recipient's condition. CRITERIA - Must meet All three A. Diagnosis: The recipient must be suffering from a mental illness, reflected in a primary, validated, DSM-IV or ICD-10 Diagnosis (not including V Codes) B. Severity of Illness (signs, symptoms, functional impairments and risk potential) At least two of the following manifestations are present: 1. psychiatric signs and symptoms (psychotic or non-psychotic clinical characteristics which suggest a significant pathological condition) 2. serious disruption of pre-existing self-care skills; diminished ability to attend to basic physical needs or to perform daily living skills; deterioration in interpersonal functioning; difficulties meeting familiaVsocial and/or educationaVoccupational role performance expectations 3. moderate danger to self 4. moderate danger to others 5. drug/medication regimen complications 1. Psychiatric Signs and Symptoms • Some prominent disturbance of thought processes, perception, affect, memory, consciousness, somatic functioning (due to a mental illness) or behavior exists (e.g., intermittent hallucinations, transient delusions, panic reactions, agitation, Utilization Management Criteria - Level of Care Determination Guidelines C-82 Page 19 obsessions/ruminations, severe phobias, depression, etc.) and is serious enough to cause disordered or aberrant conduct, impulse control problems, questionable judgment, psychomotor acceleration or retardation, withdrawal or avoidance, compulsions/rituals, impaired reality testing and/or impairments in functioning and role performance. The disordered or aberrant conduct or activity and/or the level of agitation is not so severe, extreme or unstable so as to require frequent restraints or to pose a danger to others. 2. Disruptions of Self-Care and Independent Functioning • The person seriously neglects self-care tasks (e.g., hygiene, grooming, etc.) and /or does not sufficiently attend to essentials aspects of daily living (e.g., doesn't shop, prepare meals, maintain adequate nutrition, pay bills, complete housekeeping chores, etc.) due to a mental disorder. • Recipient is able to maintain adequate nutrition, shelter or other essentials of daily living only with structure and supervision for a significant portion of the day, and with family/community support when away from the partial hospitalization program. • The person's interpersonal functioning is significantly impaired (e.g., seriously dysfunctional communication, extreme social withdrawal, etc.). • There has been notable recent deterioration in meeting educationaV occupational responsibilities and role performance expectations. 3. Danger to Self • There is modest danger to self reflected in intermittent self-harm ideation, expressed ambivalent inclinations without a plan, non-intentional threats, mild and infrequent self-harm gestures (low lethality/intent) or self-mutilation, passive death wishes, or slightly self-endangering activities. • The recipient has not made any, recent significant (by intent or lethality) suicide attempts, nor is there any well-defined plan for such activity, or, if there have been recent significant actions, these inclinations/behaviors are now clearly under control and the person no longer needs/requires 24-hour supervision to contain self-harm risk. 4. Danger to Others • Where assaultive tendencies exist, there have been no overt actions and there is reasonable expectation, based upon history and recent behavior, that the recipient will be able to curb these inclinations. Utilization Management Criteria - Level of Care Determination Guidelines C-83 Page 20 • There have been destructive fantasies described and mild threats verbalized, but the recipient appears to have impulse control, judgment, and reality orientation sufficient to suppress urges to act on these imaginings or expressions. • There has been minor destructive behavior toward property without endangerment of others. 5. Drug/Medication Complications • The recipient has experienced side effects of atypical complexity resulting from psychotropic drugs and regulation/correction/monitoring of these circumstances cannot be accomplished at a lower level of care due to the recipient's condition or to the nature of the procedures involved. • The recipient needs evaluation and monitoring due to significant changes in medication or because of problems with medication regimen compliance. C. Intensity of Service The person meets the intensity of service requirements if partial hospitalization services are considered medically necessary and the person requires at least one of the following: 1. The person requires intensive, structured, coordinated, multi-modal treatment and supports with active psychiatric supervision to arrest regression and forestall the need for inpatient care. 2. The recipient has reached a level of clinical stability (diminished risk) obviating the need for continued care in a 24-hour protective environment but continues to require active, intensive, treatment and support to relieve/reverse disabling psychiatric symptomatology and/or residual functional impairments. 3. Routine medical observation and supervision is required to effect significant regulation of psychotropic medications and/or to minimize serious side effects. Utilization Management Criteria - Level of Care Determination Guidelines Page 21 PARTIAL HOSPITALIZATION ADMISSION CRITERIA: CHILDREN AND ADOLESCENTS GENERAL JUSTIFICATION Partial hospitalization services may be used to treat a mentally ill or emotionally disturbed child or adolescent who requires intensive, highly coordinated, multi-modal ambulatory care with active psychiatric supervision. Treatment, services and supports are provided for six or more hours per day, five days a week, in a licensed setting. The use of partial hospitalization as a setting of care presumes that the recipient does not currently need treatment in a 24 hour protective environment. Conversely, the use of partial hospitalization implies that routine outpatient treatment is of insufficient intensity to meet the recipient's present treatment needs. The Severity of Illness (SO/Intensity of Service (IS) criteria for admission assume that the recipient is displaying signs and symptoms of a serious psychiatric disorder, demonstrating significant functional impairments in either self-care, daily living skill, interpersonal/social and/or educational/vocational domains, and is exhibiting some evidence of clinical instability. However, the level of symptom acuity, extent of functional impairments and/or the estimation of risk (clinical instability) does not justify or necessitate treatment at a more restrictive level of care. Medicaid coverage is dependent upon active treatment being provided at the medically necessary level of care, and the expectation that such treatment will reasonably result in improvement to the recipient's condition. CRITERIA - Must meet a three A. Diagnosis: The recipient must be suffering from a mental illness, reflected in a primary, validated, DSM-IV or ICD-10 Diagnosis (not including V Codes). B. Severity of Illness (signs, symptoms, functional impairments and risk potential) At least two of the following manifestations are present: 1. psychiatric signs and symptoms (psychotic or non-psychotic clinical characteristics which suggest a significant pathological condition) 2. serious disruption/incapacitation of self-care skills; diminished ability to attend to age-appropriate responsibilities; deterioration in interpersonal functioning; difficulties meeting familial/social and/or educational role performance expectations 3. moderate danger to self 4. moderate danger to others 5. drug/medication regimen complications 1. Psychiatric Signs and Symptoms • Some prominent disturbance of thought processes, perception, affect, memory, consciousness, somatic functioning (due to a mental illness) or behavior exists (e.g., Utilization Management Criteria - Level of Care Determination Guidelines C-85 Page 22 intermittent hallucinations, transient delusions, panic reactions, agitation, obsessions/ruminations, severe phobias, depression, etc.) and is serious enough to cause disordered or aberrant conduct, impulse control problems, questionable judgment, psychomotor acceleration or retardation, withdrawal or avoidance, compulsions/rituals, impaired reality testing and/or impairments in functioning and role performance. The disordered or aberrant conduct or activity and/or the level of agitation is not so severe, extreme or unstable so as to require frequent restraints or to pose a danger to others. 2. Disruptions of Self Care and Independent Functioning • The child/adolescent exhibits significant impairments in self-care skills (e.g., feeding, dressing, toileting, hygiene/bathing/grooming, etc.), in the ability to attend to age- appropriate responsibilities, or in self-regulation capabilities, due to a mental disorder or emotional illness. • The child/adolescent is able to maintain adequate self-care and self-regulation only with structure and supervision for a significant portion of the day, and with family/community support when away from the partial hospitalization program. • There is recent evidence of serious impairment/incapacitation in the child/adolescent's interpersonal and social functioning (e.g., seriously dysfunctional communication, significant social withdrawal and isolation, repeated disruptive, inappropriate or bizarre behavior in social settings, etc.). • There is recent evidence of considerable deterioration in functioning within the family and/or significant decline in occupationaVeducational role performance due to a mental disorder or emotional illness. 3. Danger to Self • There is modest danger to self reflected in: non-accidental self-harm gestures or self-mutilation actions which are not life-threatening in either intent or lethal potential; intermittent self-harm ideation; expressed ambivalent inclinations without a plan; non-intentional threats; passive death wishes, or slightly self-endangering activities. • The recipient has not made any, recent significant (by intent or lethality) suicide attempts, nor is there any well-defined plan for such activity, or, if there have been recent significant actions, these inclinations/behaviors are now clearly under control and the person no longer needs/requires 24-hour supervision to contain self-harm risk. C-86 Utilization Management Criteria - Level of Care Determination Guidelines Page 23 4. Danger to Others • Assaultive tendencies exist, and some assaultive behavior may have occurred, but any overt actions have been without any serious or significant injury to others, and there is reasonable expectation, based upon history and recent behavior, that the recipient will be able to curb any serious expression of these inclinations. • There have been destructive fantasies described and mild threats verbalized, but the recipient appears to have adequate impulse control, judgment, and reality orientation sufficient to suppress urges to act on these imaginings or expressions. • There has been minor destructive behavior toward property without endangerment of others. 5. Drug/Medication Complications • The recipient has experienced side effects of atypical complexity resulting from psychotropic drugs and regulation/correction/monitoring of these circumstances cannot be accomplished at a lower level of care due to the recipient's condition or to the nature of the procedures involved. • The recipient needs evaluation and monitoring due to significant changes in medication or because of problems with medication regimen compliance. C. Intensity of Service The person meets the intensity of service requirements if partial hospitalization services are considered medically necessary and the person requires at least one of the following: 1. The person requires intensive, structured, coordinated, multi-modal treatment and supports with active psychiatric supervision to arrest regression and forestall the need for inpatient care. 2. The recipient has reached a level of clinical stability (diminished risk) obviating the need for continued care in a 24 hour protective environment but continues to require active, intensive, treatment and support to relieve/reverse disabling psychiatric symptomatology and/or residual functional impairments. 3. Routine medical observation and supervision is required to effect significant regulation of psychotropic medications and/or to minimize serious side effects. C-87 Utilization Management Criteria - Level of Care Determination Guidelines Page 24 AUTHORIZATION OF PARTIAL HOSPITALIZATION CONTINUED STAY ADULTS, ADOLESCENTS AND CHILDREN RECERTIFICATION RATIONALE After a recipient has been certified for admission to a partial hospitalization program, services will be reviewed at regular intervals to assess the current status of the treatment process and to determine the continuing need for treatment in a partial hospitalization setting. Treatment within a partial hospitalization program is directed at resolution or stabilization of active signs and symptoms, elimination or amelioration of disabling functional impairments, maintenance of self/other safety, and/or close monitoring of complicated medications and/or medical conditions. The continued stay authorization process is designed to assess the efficacy of the treatment regime in addressing these concerns, and to determine whether the partial program remains the most appropriate, least restrictive, level of care for the patient. Continued stay in the partial hospitalization program may be authorized when active signs and symptoms, impairment, risk of harm, and/or medication complications, similar to those which justified the patient's admission certification, remain present, and continue to be of such a nature and severity that partial hospitalization level of care is still medically necessary. Discharge planning must begin at the onset of treatment in the program. Discharge criteria and aftercare planning are documented in the recipient's record. Payment cannot be authorized for continued stays that are due solely to placement problems or the unavailability of aftercare services. CRITERIA - Must meet a three A. Diagnosis: The recipient has a mental disorder validated by classification in the current edition of the DSM or ICD (excluding V codes), which remains the principal diagnosis for purposes of care during the period under review. B. Severity of Illness: At least one of the following manifestations is present: 1. Persistence of signs and symptoms, functional impairment, risk of harm, and/or medication complications which necessitated admission to this level of care, and which cannot currently be addressed at a lower level of care. 2. Emergence of new signs and symptoms, impairments, harm inclinations or medication complications, meeting admission criteria. C. Intensity of Service Must meet au of the following: 1. The recipient is receiving timely, intensive, structured multi-modal treatment delivered according to an individualized plan of care. Utilization Management Criteria - Level of Care Determination Guidelines C-88 Page 25 2. Treatment is directed toward stabilizing or diminishing those symptoms, functional impairment, risk of harm, or medication complications which necessitated admission to the program. 3. Recipient is making progress towards specific treatment goals, or if no progress has been made within an expected time frame based on prescribed treatment, the treatment plan and therapeutic program have been recently revised accordingly, and there is a reasonable expectation of a positive response to treatment. 4. Discharge criteria are established and aftercare planning and implementation are ongoing. Utilization Management Criteria - Level of Care Determination Guidelines C-89 Page 26 INTENSIVE CRISIS STABILIZATION SERVICES CRITERIA: ADULTS, ADOLESCENTS AND CHILDREN GENERAL JUSTIFICATION Intensive Crisis Stabilization Services are an intensive combination of community-based treatment and supports, provided to a persons in crisis, at a place or places chosen by the person and his/her support system, intended as a substitute for hospital emergency room services and/or inpatient psychiatric care. It is the intensity of the services and supports provided, rather than the setting, which distinguishes this level of care. The Severity of Illness (SI)/Intensity of Service (IS) criteria for admission are based upon the assumption that the recipient is experiencing a severe psychiatric crisis (signs and symptoms of an mental disorder, impaired functioning and coping abilities, a significant degree of clinical instability) and is considered to be at risk of inpatient hospitalization or out-of-home placement unless considerable support and intensive interventions are provided. Intensive crisis stabilization services may also be appropriate for individuals recently discharged from protective care facilities, if such services are used to decrease the length of stay in the protective environment or to forestall the need for readmission to the facility. Medicaid coverage is dependent upon active treatment being provided at the medically necessary level of care, and the expectation that such treatment will reasonably result in improvement to the recipient's condition. CRITERIA - Must meet all three A. Condition: The recipient must be suffering from an acute problem of disturbed thought, memory, perception, behavior, mood or social relationship (reflected in a primary, validated, DSM-IV or ICD-10 Diagnosis, not including V Codes) which requires both immediate intervention and sustained support over a limited period of time. Persons exhibiting residual impairments after discharge from an inpatient psychiatric stay may also be suitable for application of this level of care intensity if it will significantly reduce the risk of relapse. B. Severity of Illness (signs, symptoms, functional impairments and risk potential) At least Iwo of the following manifestations is present: 1. emotional distress/psychiatric signs and symptoms of substantial acuity. 2. disruption-temporary incapacitation of daily living skills, social functioning and/or ability to meet educational/occupational role performance expectations. 3. marginal risk of danger to self/others. 1. Emotional Distress - Psychiatric Signs and Symptoms • Acute, substantial, disturbance of cognition, memory, mood/affect, perception and/or behavior due to severe emotional distress or mental illness, with conjoint functional impairments. C-90 Utilization Management Criteria - Level of Care Determination Guidelines Page 27 • Symptom acuity does not pose an immediate risk of substantial harm to the person or others, or if a risk of substantial harm exists, protective care (with appropriate medical/psychiatric supervision) has been arranged. 2. Disruptions of Self-Care and Independent Functioning • The person exhibits an acutely diminished ability to perform activities of daily living independently, appropriately and/or effectively, and/or to function adequately in familial, social, and educational/occupational roles due to substantial emotional distress or an acute mental disorder. • The person is able to attain or maintain adequate ability/performance in self-care, daily living skills, interpersonaVsocial, and/or educational/occupational domains only with sustained support and assistance. • Current impairment/incapacitation in functioning represents a change from baseline ability/performance, and will likely remit or subside with time-limited intensive support and assistance. 3. Danger to Self/Others • Person verbalizes passive death wishes or ideas, intermittent self-harm ideation without a plan, fleeting thoughts of methods/means without sustained intent, expressed ambivalent inclinations. • Person engages in non-serious, mildly self-injurious actions (minor self-mutilation) as a gesture of discontent or as a parasuicidal coping mechanism (personality disorder). • The recipient has not made any recent, significant (by intent or lethality) suicide attempts, nor is there any well-defined plan for such activity. • Person verbalizes minor threats or expresses non-specific hostility toward others, but appears to have sufficient judgment and impulse control to avoid acting on these impulses. There is no recent history of violent or seriously destructive acts. C. Intensity of Service The person meets the intensity of service requirements if intensive crisis stabilization services are considered medically necessary to ameliorate disabling effects of the crisis situation, improve the recipient's condition and/or allow the person to function without more restrictive care, and the person requires at least one of the following: 1. The person is experiencing an acute psychiatric crisis and requires intensive, coordinated and sustained treatment services and supports at multiple sites to maintain functioning, arrest regression and forestall the need for inpatient care. 2. The recipient has reached a level of clinical stability (diminished risk) obviating the need for continued care in a 24 hour protective environment but require intensive, coordinated, services and supports at multiple sites for a limited time to address residual functional impairments. Medicaid Managed Mental Health Care Program Quality Improvement and Performance Monitoring Plan Dimension Page Dimension I: Attributes of Care 2 Dimension II: Appeals/Reconsiderations 7 Dimension III: Satisfaction 8 Dimension IV: Service Utilization 10 Dimension V: Expenditures Targets 11 Application of Clinical Criteria Appendix A Data Elements Appendix B Required Reports Appendix C Satisfaction Survey Questions Appendix D C-91 Revised 10/1/96 C-92 INTRODUCTION The Quality Improvement and Performance Monitoring Plan (QIPMP) for the Medicaid Managed Mental Health Care Program was implemented in August 1995 to establish performance requirements for CMH and to describe the mechanisms to be used to evaluate CMH execution of key responsibilities. In the first year of the Medicaid initiative the QIPMP was comprehensive and detailed. CMH performance was examined and reviewed along a number of quality indicator dimensions including, a) timeliness of review activities (accessibility of review services); b) attributes of care measures (application of clinical criteria, coordination of care, relapse/recidivism rates, out-of-state placements, credentialling/privileging etc.); c) recipient and provider reconsidera- tion and appeals; and d) recipient/family and provider/referral source satisfaction; as well as more detailed and traditional monitoring dimensions such as, e) service utilization by levels of care; and f) board performance relative to expenditure targets established by the Department of Community Health. Community Mental Health was required to collect data pertinent to the program, perform internal quality monitoring and improvement activities, furnish a number of reports to DCH, and sample recipients and providers to gauge their satisfaction with CMH performance. In FY 96/97, where possible, reports that were developed for the Medicaid managed mental health care initiative are to be merged with ongoing DCH/Behavioral Health Quality Improvement efforts. These include the dimensions on timeliness which will be incorporated into 01/Access measures and recipient satisfaction. Other reporting requirements have been modified consistent with the ongoing managed care planning efforts to focus on the critical areas of performance and utilization. While the reports to DCH have therefore been significantly streamlined, it is DCH/Behavioral Health expectation that the CMHs will retain the data collection and local level reports to continue to assist the local CMH system in monitoring its managed care activities. In FY 96/97, CMH performance will reviewed along the following quality indicator dimensions: Attributes of Care: Application of clinical criteria Coordination of care Relapse/recidivism Out-of-state placements Credentialling/privileging Recipient and provider reconsideration and appeals Provider/referral source satisfaction In addition, there will be detailed traditional monitoring of service utilization and expenditures. DCH policy requires that each Community Mental Health develop and implement a quality improvement plan to identify and resolve problems or quality issues in the provision of care and services. CMHs must utilize these existing quality improvement plans and processes to regularly sample, evaluate and refine their execution of key program activities and performance objectives. DCH will assess the adequacy and effectiveness of CMH quality C-93 Medicaid Managed Mental Health Care Program Quality Improvement and Performance Monitoring Program Page 2 improvement activities relative to this program through quarterly reports and by way of the DCH site review for Medicaid certification. DCH will issue a compliance report no later than 30 days following the monitoring review. The CMHSP is required to submit a Plan of Improvement within 30 days after receiving a report from DCH indicating variances from standards and procedures in Attachment C. The CMHSP is required to perform within the standards and procedures within 150 days of the Plan of Improvement. QIPMP dimensions are described in more detail below. A list of items relevant for auditing the application of level of care protocols is contained in Appendix A. The directory of data elements and definitions for the review activities are contained in Appendix B. A schedule of required reports is included in Appendix C. Finally, some standard questions for inclusion in the provider satisfactions survey are described in Appendix D. QIPMP Dimension I: Attributes of Care 1. Application of Clinical Criteria a. Inpatient Reviews Standard: The CMH will monitor, through its established QI process • Adherence to Clinical Criteria (staff consistency in conducting and recording review services according to the "Inpatient Pre-Admission and Episode Management Procedures" outlined in Attachment C of the DCH/CMH Contract, and in applying DCH "Utilization Management Criteria - Level of Care Guidelines "during review activities). • Quality of Review Decisions and Dispositions. Performance Objective: • >95% of all pre-admission screenings and continued stay reviews should be managed according to published DCH criteria. Monitoring reports to DCH will include a report on performance on this dimension. DCH will monitor this dimension through the review of these reports and through the site review for Medicaid certification, which will include both a sample of cases and review of the CMHSP's QI activities. b. Partial Hospitalization Standard: The CMH will monitor, through its established QI process • Adherence to Clinical Criteria (staff consistency in conducting and recording review services according to the "Partial Hospitalization Review Procedures" outlined in Attachment C of the DCH/CMH Contract, and in applying DCH "Utilization Management Criteria - Level of Care Guidelines" during review activities). • Quality of Review Decisions and Dispositions. C-94 Medicaid Managed Mental Health Care Program Quality Improvement and Performance Monitoring Program Page 3 Performance Objective: • >95% of all pre-admission screenings and continuing stay reviews should be managed according to published DCH criteria. Monitoring reports to DCH will include a report on performance on this dimension. DCH will monitor this dimension through review of these reports and through the site review for Medicaid certification, which will include both a sample of cases and review of the CMH's QI activities. NOTE: Appendix A contains a detailed list of items which CMHs should incorporate in their review processes when appraising the application of clinical criteria. 2. Coordination of Care - Communication Between CMH and the Recipient's Primary Care Provider When CMH becomes involved with a Medicaid recipient who is enrolled with a managed primary health plan (HMO, Clinic Plan, PSP or other qualified health plans) or with a recipient who is not in a managed primary health care plan, the recipient's primary care physician (PSP or other) or Health Plan (QHP, HMO, Clinic Plan, or other) must be notified on a timely basis of significant developments regarding that recipient. Standard: • CMH will notify the physician/Health Plan within two (2) work days regarding key events (inpatient admission, partial hospitalization admission, discharge dates from inpatient or partial hospitalization episodes, etc.) • CMH will notify the physician/Health Plan after significant changes (medication initiation or major change, suicidal behavior, discharge/termination, etc.) in the mental health or physical health status of the recipient. Performance Objective: • >95% of screening dispositions will be communicated to the primary care physician/Health Plan within established time frames. This standard does not apply if the recipient is not enrolled in a managed care plan and does not have a primary physician. • >75% of CMH cases selected for review will document timely CMH notification to the primary care physician/Health Plan of significant changes in a recipient's mental health or physical health status or in the recipient's mental health treatment. This standard does not apply if there are no significant changes to report or if the recipient will not release information. CMH must establish internal procedures to ensure exchange of information with the physician on a timely basis and must monitor such notifications through recipient record sampling and QI activities. DCH will review such procedures and internal compliance audits during the site visit for Medicaid certification. Medicaid Managed Mental Health Care Program Quality Improvement and Performance Monitoring Program Page 4 Primary physicians/Health Plans should also provide pertinent information to CMH if they refer a recipient for mental health services, or if one of their enrollees self-refers to CMH. CMH must monitor whether they are receiving, in a timely fashion, necessary required or requested information from the recipient's primary care physician/Health Plan. This applies to both recipients that are referred by the physician/Health Plan as well as for those recipients who self-refer to CMH. Each CMH must notify physicians/Health Plans within the CMH's catchment area regarding the information and releases which should accompany any referral for CMH services. For self-referrals, CMH is expected to contact the primary physician/ Health Plan to inform them about the self-referral and to request relevant medical information from the primary provider. If required or requested information is delayed or incomplete, for either provider-referred or self-referred recipients, CMH must follow up with the provider through the CMH QI program to obtain necessary information and to remedy information exchange difficulties. Due to the importance of coordination CMHs will be expected to continue to monitor local coordination and exchange of information with the primary physician/Health Plans, but no report to DCH will be required. 3. Psychiatric Inpatient Relapse/Recidivism Medicaid recipients who are readmitted to a psychiatric inpatient unit within fifteen (15) days of discharge from an inpatient episode must be reviewed through a CMH utilization review or risk management process. Each CMH must monitor, through its established QI process, the patterns (if any) surrounding such occurrences and must develop plans of improvement to deal with such situations/patterns as necessary. Standard: • All cases readmitted within 15 days of discharge will be reviewed. Performance Objective: • <15% of recipients will be readmitted within 15 days of discharge. Monitoring reports to DCH will include data (by hospital of discharge) on this dimension including total number of readmissions (within 15 days) during the reporting period and compliance with the clinical review requirement. 4. Out of State Placements Under the Medicaid managed mental health services program, CMHs have responsibility for admission authorization, continuing stay reviews and Medicaid payment authorization for children/adolescents who are referred for, or who are currently receiving, Medicaid- funded psychiatric inpatient services from an out-of-state, non-enrolled hospital. C-95 Medicaid Managed Mental Health Care Program Quality Improvement and Performance Monitoring Program Page 5 .C-96 Standard: • CMH will authorize and provide continuing stay review services for all children/ adolescents who are referred for, or who are currently receiving, Medicaid-funded psychiatric inpatient services from an out-of-state, non-enrolled hospital. Performance Objective: • 100% of such cases will be certified/reviewed/monitored by CMH per DCH procedures outlined in contract Attachment C ("Out of State Children Psychiatric Inpatient Placements"). CMH will be required to provide a report each quarter of the status of out-of-state placements. This will include information about each admission, authorized days, expiration date for current authorization, planned discharge date, and hospital rate to be paid by Michigan Medicaid. 5. Credentialling and Privileging_ of CMH Staff Conducting Review Activities Standard: • Each CMH must have an internal credentialling and privileging process to ensure that staff performing review activities are competent to provide such services. Performance Objective: • 100% of CMH staff performing screenings/reviews will be credentialed/privileged. With the first quarter report, October -December 1996, DCH will require each CMH to provide information to the Department regarding the CMH's procedures for credentialing/privileging staff. This report will also include information on the numbers and type of staff privileged for each of the review activities: Inpatient pre-admission screening, inpatient episode management, partial hospital preadmission screening, partial hospitalization episode management, reconsideration reviews. During the site review for Medicaid certification, the CMH must provide documentation regarding its credentialing and privileging program, (including information on the yearly reprivileging process) and must substantiate that all individuals providing review activities on behalf of the CMH have been properly evaluated and certified by that program. OIPMP Dimension II: Reconsiderations and Appeals 1. Recipient/Family Appeals Medicaid enrollees who disagree with CMH screening/review decisions or who feel their rights as service recipients have been violated can appeal through the FIA County Office or if they are a CMH client complain through the CMH Recipient Rights system. C-97 Medicaid Managed Mental Health Care Program Quality Improvement and Performance Monitoring Program Page 6 Most CMHs use some form of internal clinical review system to address requests by clients regarding service arrangements or level of care placement decisions. It is generally only after the clinical review process has proven unsatisfactory that a formal rights complaint is filed. CMH clients who are Medicaid recipients included in the managed mental health services program may utilize existing CMH clinical review processes such as request for reconsideration of decisions and the CMH's recipient rights system to complain about CMH screening/review decisions. For monitoring purposes, all client grievances of screening/review decisions, made either through internal clinical review processes or through the recipient rights system, should be tracked and reported. The number, type, and resolution of clinical review requests/reconsiderations of Medicaid screening/review decisions for CMH recipients will be tracked and monitored by each CMH. Monitoring reports to DCH will include data on this dimension. 2. Provider Reconsiderations and Appeals Physicians/psychiatrists and hospitals can request the reconsideration of CMH pre- admission screening decisions and continued stay decisions for inpatient and partial hospitalization (PHP) services. If a physician/psychiatrist or hospital disagrees with the reconsideration decision, and the recipient was admitted to the hospital or PHP, they may appeal to MSA. The number, type, and resolution of inpatient and PHP reconsiderations will be monitored by CMH and DCH. The number type and resolution of provider appeals will be monitored by DCH. CIIPMP Dimension III: Provider/Referral Source Satisfaction 1. Referral source and Other Providers Satisfaction It should be noted that recipient/family satisfaction will be addressed through the overall DCH/Behavioral Health Quality Improvement program. Each CMH must have a method of sampling provider satisfaction with CMH services. This is in accordance with the Department's emphasis upon continuous quality improvement as a guiding philosophy for the public mental health system. For the purpose of Medicaid managed mental health services program, CMHs will incorporate a set of standard questions into their existing provider satisfaction surveys and sampling processes. The standard question set is a measure of provider/referral source satisfaction with the accessibility, appropriateness and usefulness of CMH services, including the specific activities covered by this program. C-98 Medicaid Managed Mental Health Care Program Quality Improvement and Performance Monitoring Program Page 7 DCH will assess CMH survey design, sampling approach and techniques, response rates and satisfaction levels, through the contract management process. Each CMH should report and monitor provider satisfaction through their established QI process. Reports to DCH will include CMH data on satisfactions levels, with specific information on responses to the standard question set for the Medicaid managed mental health services program. Standard: • Each CMH must incorporate a set of standard questions for PSP and other primary physicians, hospitals, substance abuse coordinating agencies, QHPs, HMOs and Clinic Plans into their community/agency survey process. Performance Objective: • >75% of those who respond to provider satisfaction assessments will agree or strongly agree that they are "...satisfied with the services provided by CMH". CMH will report and monitor provider satisfaction through their QI process and will report data on this dimension to DCH on an basis. The report on this dimension is to be only submitted once with the July-September 1997 quarterly report. OIPMP Dimension IV: Service Utilization by Levels of Care The focus of this dimension is primarily directed toward examining service utilization patterns of Medicaid recipients. Specifically, the program seeks to track the utilization of inpatient, crisis residential, crisis stabilization and partial hospitalization services by PSP enrollees and those Medicaid recipients not in a managed primary care plan, and expanded coverage to all Medicaid recipients as of 1/1/97. The following list identifies utilization data that must be collected/monitored by CMH, with summary reports as indicated by an asterisk (*) of a subset of this data to be provided through quarterly reports to DCH. Crisis Services/Inpatient Pre-Admission Screenings Activities 1. Disposition of pre-admission screenings (summarized by disposition category). 2. Specific use of alternative crisis services (crisis residential and crisis stabilization) and number of admissions to alternative services, summarized by type of Medicaid managed primary care plan, including non-managed care recipients. Inpatient Services 1. CMH Review Activity Volume. 2. CMH Denial Activity. 3. Inpatient use (admissions, days, LOS) by diagnostic category. • Medicaid Managed Mental Health Care Program Quality Improvement and Performance Monitoring Program Page 8 * 4. Inpatient use: number of admissions, total number of days of care, a rough calculation of average episode of care duration (number of days of care during reporting period divided by number of admissions during reporting period), unique number of recipients. 5. Psychiatric inpatient use by persons with co-existing substance abuse symptom analyses: number of admissions, total days of care, average days/admission. 6. Readmission patterns, with particular reference to readmission within fifteen days. 7. Summary of discharge plan data (by type of discharge plan). * 8. Trend reports of use over time (e.g. admissions, days of care, length of stay, admission rates, use rates). Partial Hospitalization 1. CMH Review Activity Volume. 2. CMH Denial Activity. * 3. Use : admissions, days of care, average days of care per episode, number of unique recipients. 4. Summary of types of discharge plans. * 5. Trend analysis of use over time (e.g. admissions, days of care, days per case, days per episode, admission rates, use rates). Alternative Crisis Services * 1. Number of admissions, number of unique/unduplicated cases and total number of days of care for crisis residential. * 2. Number of admissions, number of unique/unduplicated cases, and units of service for crisis stabilization Outpatient Services 1. Number of Medicaid recipients who are Medicaid Clinic Plans or HMOs enrollees served in CMH Provider Type 21 Services. 131PMP Dimension V: Expenditures Targets The Medicaid managed mental health services program will also examine cost of care trends, in addition to the aforementioned matters of recipient access, care quality indicators, recipient/provider satisfaction and utilization patterns. The premise of the program is that CMHs, if given clear gatekeeping/utilization management responsibilities for high cost levels of care and suitable diversion options, can impact Medicaid expenditures for mental health care in their county catchment areas. In FY 96/97 this gatekeeping and episode management process will be strengthened by placing the CMH into a risk-based contract for the Medicaid expenditures that result from their decisions. Each CMH will be monitoring its performance against a CMHSP expenditure cap set by DCH. The CMH will be able to use the state share savings if expenditures are less than the cap. If expenditures exceed the cap, the CMH's state share for its community programs will be reduced by the amount needed to cover the Medicaid paid claims. C-99 Medicaid Managed Mental Health Care Program Quality Improvement and Performance Monitoring Program Page 9 C.-100 In monitoring actual CMH performance against the cap, it is imperative that the CMH maintain accurate estimates of expenditures for the various Medicaid services included in this program. Expenditures estimates should be based upon services utilization and payment rate information for various facilities and levels of care. Where necessary, adjustments should be made for co-payments and deductibles. The following expenditure estimates should be monitored by CMH and reported to DCH according to the schedule below: 1. Monitoring of service activity and Medicaid payment liability compared to target (monthly monitoring by CMH, quarterly report to DCH): a. Inpatient b. Partial Hospitalization c. Crisis Residential d. Crisis Stabilization 2. Monitoring of screening and review activities, costs, and reimbursements (monthly monitoring by CMH, quarterly report to DCH): a. Pre-admission screening for inpatient care b. Inpatient episode management c. Inpatient retrospective reviews d. Partial hospitalization pre-admission reviews e. Partial hospitalization episode management f. PHP retrospective reviews g. Reconsiderations and appeals Medicaid Managed Mental Health Care Program Quality Improvement and Performance Monitoring Program Page 10 C-101 APPENDIX A APPLICATION OF CLINICAL CRITERIA The following is a set of the items and criteria - relevant for auditing the implementation of review procedures and the application of level of care protocols-which should be incorporated into the CMHSP's Utilization Review and Quality Improvement process. These items/criteria are derived from information in Attachment C (i.e., the "checklists" for conducting review activities and the utilization management criteria) and will be incorporated into the "sample of cases" audit performed during the Medicaid certification reviews conducted by DCH Office of Monitoring. Inpatient Pre-admission Screening Reviews and Episode Management 1. Review of a sample of records of both face-to-face and phone reviews for consistent application of the pre-admission screening assessment procedures. Sample to include cases that were diverted as well as cases certified for inpatient admission. a. Emergency referrals - Pre-admission review conducted within 3 hours of referral/request. b. Non-emergency inpatient requests - pre-admission review conducted within 7 calendar days of request, with consideration of urgency of request resulting in a more rapid response. c. If recipient presented with both mental health and substance abuse problems, documentation of efforts to coordinate with substance abuse treatment system, including CDR if required. d. Completion of general information about recipient, including Medicaid status. e. If HMO or Clinic Plan enrollee, documentation of contact with capitated plan manager and disposition. f. Completion of General Clinical Considerations information: factors that precipitated crisis, diagnosis and substantiation, medication assessment, treatment history. g. Severity of Illness assessment completed. h. Intensity of Service assessment completed including information about alternatives considered and why rejected. I. Completion of Special Considerations information as needed. j. Certification form completed and documented as sent to hospital. k. Admission authorization number issued to hospital. I. Information on referral to alternative. m. If recipient from another county, documentation of contact/communication with the other CMHSP. 2. Review of a sample of inpatient continuing stay reviews for consistent application of review procedures. Sample to also include cases that were reviewed through retrospective review procedures. a. Reviews conducted on a timely basis. Quality Improvement and Performance Monitoring Plan C-102 Appendix A: Application of Clinical Criteria Page 11 b. Completion of General Considerations and Status of Treatment information: diagnostic and level of functioning information, progress in treatment, medication response, discharge plans. c. For retrospective reviews, completion of information that justified the need for admission. d. Severity of Illness assessment completed. e. Intensity of Service assessment completed. f. If admission or days of care denied, documentation of the reasons for denial was completed. g. Payment authorization number issued to hospital. h. If recipient from another county, documentation of communication with other CMHSP. 3. Review of a sample of reconsiderations. a. Reconsideration of pre-admission reviews conducted within 3 work days. b. Reconsideration of continued stay reviews conducted within 3 work days. c. Reconsideration of retrospective reviews conducted within 30 days. d. Consistent consideration of criteria documented. e. If reconsideration upheld original decision, copy sent to provider, DCH/MSA Hearing Office, and DCH/Behavioral Health. 4. Staff consistency and competency in conducting reviews. a. Review of agency policy and procedures for personnel assessment and credentialing/privileging process, with particular reference to assessing the competency of staff to perform these reviews (pre-admission, continued stay, retrospective, reconsideration). b. Review of a sample of staff personnel and C/P records. 5. Review of CMH Quality Improvement activity in this area. a. Review of CMHSP QI plan/program and standards b. Review reports and results of QI activity c. Assess agency QI efforts to ensure quality of pre-admission screening decisions and dispositions. d. Assess agency QI efforts to ensure quality of episode management reviews, length of stay decisions, and discharge planning. e. Review of Improvement plans and plans of correction Partial Hospitalization Reviews 1. Review of a sample of records of both face-to-face and phone reviews for consistent application of the admission and continued stay assessment procedures. Sample to include cases that were diverted as well as cases certified for partial hospitalization admission. • Quality Improvement and Performance Monitoring Plan Appendix A: Application of Clinical Criteria Page 12 C-103 a. Referrals from inpatient - admission review conducted within 2 days of referral/request. b. Community referrals - admission review conducted within 5 work days of request, with consideration of urgency of request resulting in a more rapid response. c. If recipient presented with both mental health and substance abuse problems, documentation of efforts to coordinate with substance abuse treatment system, including CDR if required. d. Completion of general information about recipient, including Medicaid status. e. If HMO or Clinic Plan enrollee, documentation of contact with capitated plan manager and disposition. f. Completion of General Clinical Considerations information: factors that precipitated request, diagnosis and substantiation, medication assessment, treatment history, etc. g. Severity of Illness assessment completed. h. Intensity of Service assessment completed including information about alternatives considered and why rejected. I. Completion of Special Considerations information as needed. j. Admission authorization form completed and documented as sent to hospital as needed. k. Information on referral to alternative. I. Continued stay reviews completed within 2 work days. m. Continued stay review record includes required information on changes in diagnosis and level of functioning; severity of Illness and risk assessment; status of treatment; discharge plans. n. Continued stay and days of stay authorization form completed and documented as sent to PHP. o. If recipient from another county, documentation of contact/communication with other CMHSP. 2. Review of a sample of reconsiderations a. Reconsideration conducted within 5 work days. b. Consistent consideration of criteria documented. c. If reconsideration upheld original decision, copy sent to provider, MSA Hearings Office, DCH/Behavioral Health 3. Staff consistency and competency in conducting reviews a. Review of agency policy and procedures for personnel assessment and Credentialing/privileging process with particular reference to assessing the competency of staff to perform these reviews. b. Review of a sample of staff personnel and C/P records 4. Review of CMH Quality Improvement activity in this area. a. Review of CMH QI plan/program and standards. Quality Improvement and Performance Monitoring Plan Appendix A: Application of Clinical Criteria Page 13 C-104 b. Review reports and results of QI activity. c. Assess agency 01 efforts to ensure quality of partial hospitalization admission and continuing stay review decisions and dispositions. d. Review of Improvement plans and plans of correction. Coordination with Primary Health Care Review of a sample of records for documentation of coordination with primary health care: 1. Notified primary physician or Health Plan of key events within 2 days. 2. Notified primary physician or Health Plan after significant changes in the mental health or physical health status of the recipient. 3. Received referral information from primary physician/Health plan. Relapse/Recidivism 1. Review of records for Medicaid recipients who are readmitted to psychiatric inpatient unit within 15 days of discharge from a psychiatric inpatient episode. a. Case was reviewed by CMH UR or risk management process. b. Factors resulting in readmission identified. c. Was the discharge/readmission identified as justified/appropriate? d. Were individual and/or systemic factors identified and plans of improvement developed as needed? Out-of-State placements Review of records of all out-of-state placements: 1. Admission was necessary and all forms completed and sent. 2. Continuing stay reviews conducted on a timely and complete basis and all forms/documentation sent. C-105 APPENDIX B Inpatient Review and Medicaid Authorization MINIMUM DATA REQUIREMENTS - DEFINITIONS PRE-ADMISSION SCREENING DATA ELEMENT Date of referral/request Time of referral/request Time of start of screening Time of completion of screening Date of completion of screening (non-emergent) Referral/Request source CMH Clinical Screener (Name) CMH Clinical Screener (ID #) CMH Psychiatrist (Name) CMH Psychiatrist (ID #) Type of screening Location of screening Patient Name Address Street City State Zip County of Residence Name Code # Date of Birth Sex TYPE Date Time Time Time Date Coded/Numeric Character Numeric Character Numeric Coded/Numeric Coded/Numeric Character Character Character Character Numeric Character Numeric Date Coded/Numeric FIELD FORM mm/dd/yy hh/mm am or pm hh/mm am or pm hh/mm am or pm mm/dd/yy 1 =Self 2=Family 3=Physician/PSP 4=Psy3hiatrist 5=HospitaVER 6=Hospital/Inpatient 7=HospitaVPHP 8=Law enforcement 9=CMH program/staff 10=Other MH 1 1 =Other Alpha Digits (local) Alpha Digits (local) 1=Phone 2=Face to Face 1=Phone 2=CMH site 3=Hospital ER 4=Community Alpha Alphanumeric Alpha Alpha 5 Digit Alpha 2-Digit mm/dd/yy 1 =Male 2=Female TYPE Numeric Coded/Numeric Character Character Character Coded/Numeric Character Coded/Numeric Date Character Date Numeric Diagnosis (DSM IV) Axis 1-Primary Axis 1-Secondary (Optional) Axis 2 Axis 3 Axis 4 Axis 5 SWIS Used Five digit code(s) Coded/Numeric 1=Adult 2=ChilcVAdolescent C-106 Quality Improvement and Performance Monitoring Plan Appendix B - Inpatient Data Elements Page 15 Coded/Numeric Coded/Numeric Numeric Character Numeric Character Numeric PRE-ADMISSION SCREENING DATA ELEMENT Medicaid # Medicaid Managed Care Plan(Level of Care) If PSP, Physician Sponsor Name If HMO, Name of HMO If Clinic Plan, Name of Clinic Plan Insurance Information: Other Primary Insurance? If Yes, Name of Other Primary Insurance Medicaid Potential CMH Status Other CMH Unique CMH Client Identifier CMH Case Manager Name CMH Case Manager ID Number Attending/Treating Physician Attending/Treating Physician ID Number Clinical Information: Last Psychiatric Hospitalization (admission) Hospital Name Discharge Date FIELD FORM Digits 1=PSP 2=HMO 3=Clinic Plan 4=Not enrolled Alpha Alpha Alpha 1=Yes 2=No Alpha 1=Spend-down 2=Dual coverage 3=Appears to meet Medicaid qualifications 1=Open 2=Closed 3=Never open in CMH County code Digits (local) Alpha Digits (local) Alpha Digits (local) mm/dd/yy Alpha mm/dcVyy TYPE Coded/Number Coded/Numeric Coded/Numeric Numeric Range 1-6 Depending Care Level C-107 ' Quality Improvement and Performance Monitoring Plan Appendix B - Inpatient Data Elements Page 16 Coded/Numeric Code/Numeric PRE-ADMISSION SCREENING DATA ELEMENT Level of Care SI/IS Used for Disposition Severity of Illness Primary category Secondary Category Substance Abuse Symptoms MR/DD Dual Diagnosis Intensity of Services FIELD FORM 1=Inpatient 2=Crisis Residential 3=Partial Hosp 4=Crisis Stabilization 1=Severe signs/symptoms 2=SeIf-care/functioning 3=Harm to self 4=Harm to Others 5=Drug/med complications NOTE: Recommend also identify sub-category per SI/IS 1=Severe signs/symptoms 2=SeIf-care/functioning 3=Harm to self 4=Harm to Others 5= Drug/med complin 1=Yes 2=No 1=Yes 2=No 1 Digit Disposition: Inpatient Admission Hospital: Name License # Phone # Status Admission Date Admission Time Coded/Numeric Character Numeric Numeric Coded/Numeric Date Time 1=Yes 2=No Alpha Digit 10 Digit 1=Voluntary 2=Involuntary mm/dd/yy hh/mm am or pm TYPE Coded/Numeric Coded/Numeric Coded/Numeric Coded/Numeric Date Time Date Time TYPE Date Time Character Numeric Coded/Numeric Character Numeric Character Numeric Coded/Numeric Numeric Coded/Numeric ' c-ioa Quality Improvement and Performance Monitoring Plan Appendix B - Inpatient Data Elements Page 17 Coded/Numeric PRE-ADMISSION SCREENING DATA ELEMENT Alternative Crisis Service? Type of Program Referred to Outpatient/Ambulatory Support Services? Type of Program Crisis Resolved No Other Service Needed Communication about Prescreening: Contact with Other CMHSP Contact with primary physician/Health Plan CONTINUING STAY DATA ELEMENT Date of Review Time of Review CMH Reviewer Name CMH Reviewer ID Number Type of Review Hospital Name Hospital ID Number Hospital Person providing information Admitting Diagnosis Diagnosis Change? New Diagnosis Severity of Illness Status (Per SI/IS for Continuing Stay) FIELD FORM 1=Yes 2=No 1=Crisis Residential 2=Crisis Stabilization 3=Other 1 =Yes 2=No 1=ACT 2=Case Manager/Clinician 3=Outpatient 4=Private MH Provider 5=Substance Abuse 6=PHP 7=Other 1=Yes 2=No mm/yy/dd hh/mm mrn/dd/yy hh/mm FIELD FORM mm/yy/dd hh/mm am or pm Alpha Digit (local) 1=On-site at hospital 2=Phone Alpha ? Digit Alpha 5-Digit 1=Yes 2=No Five digit code(s) 1=Persistence/Intensified 2=New Factors 3=N/A-Cont. Stay Not Approved .„ Quality Improvement and Performance Monitoring Plan Appendix B - Inpatient Data Elements Page 18 TYPE Coded/Numeric Date Coded/Numeric Coded/Numeric Coded/Numeric Numeric Coded/Numeric Numeric Coded/Numeric Date Time Date Date Time Date Time PRE-ADMISSION SCREENING DATA ELEMENT Intensity of Service Status Estimated Discharge Date Consultation with CMH Supervisor? Consultation with CMH Psychiatrist Decision: Approved All Days of Care to Date Days Approved Denied Some/All Days of Care Days Denied Reasons for denial Date Decision was Communicated to Hospital Time of Decision Communicated to Hospital Next Review Date Communication re: Days of Stay Authorization: Contact with Other CMHSP Contact with primary physician/Health Plan C-109 FIELD FORM 1=Requires close observe & medical supervision 2=Receiving active tx according to an IPS 3=Tx reducing factors that necessitated admission 4=Progress toward goals or, if no progress, tx plan has been revised mm/dd/yy 1=Yes 2=No 1=Yes 2=No 1=Yes 2=No 2 Digit 1=Yes 2=No 2-Digit 1=Untimely Review Documentation 2=Lacking Sufficient Documentation 3=Client No Longer Meets SI/IS Criteria mm/dd/yy hh/mm am or pm mm/dd/yy mm/yy/dd hh/mm mm/dd/yy hh/mm Date Coded/Numeric Date of Request Reason for Request Quality Improvement and Performance Monitoring Plan Appendix B - Inpatient Data Elements Page 19 DISCHARGE REVIEW DATA ELEMENT Actual Discharge Date Total Days of Stay Days Approved Days Denied Medicaid Payment Authorization Number Discharge Plan Communication re: Discharge: Contact with Other CMHSP Contact with primary physician/Health Plan RETROSPECTIVE REVIEW DATA ELEMENT TYPE Date Numeric Numeric Numeric Numeric Coded/Numeric Date Time Date Time TYPE FIELD FORM mm/dd/yy 2-Digit 2-Digit 2-Digit ? Digit 1=Partial Hospital 2=To CMH Cris Res/Stabil. 3=To Other CMH Services 3=To Private MH 4=To Sub. Abuse 5=Other mm/yy/dd hh/mm mrn/dd/yy hh/mm FIELD FORM Name of Other Insurance (if any) Attending Physician (Name) Attending Psychiatrist (ID #) Date of Retrospective Review Patient Name Address Street City State Zip Character Character Numeric Date Character Character Character Character Numeric mrn/dd/yy 1=Other Insur. Exhausted 2=Retro Medicaid Eligibility 3=Other Alpha Alpha Digits mm/dd/yy Alpha - Alphanumeric Alpha Alpha 5-Digit Character Numeric Date Coded/Numeric Date Numeric Coded/Numeric Quality Improvement and Performance Monitoring Plan Appendix B - Inpatient Data Elements Page 20 C-1 11 TYPE Character Character Character Character Numeric Date Date Numeric Numeric Coded/Numeric Coded/Numeric Coded/Numeric Coded/Numeric RETROSPECTIVE REVIEW DATA ELEMENT County of Residence Name Code # Date of Birth Sex Date Retrospective Medicaid Eligibility Established Medicaid # Medicaid Managed Care Status(Level of Care) If PSP, Physician Sponsor Name If HMO, Name of HMO If Clinic Plan, Name of Clinic Plan Name of Hospital Requesting Retro Review Hospital ID Number Date of Patient Admission to Inpatient Date of Discharge from Inpatient Total Number of Days of Care Provided Admitting Diagnosis Axis 1 (Primary) Axis 1 (Secondary) Axis 2 Substance Abuse Symptoms MR/DD Dual Diagnosis? SI/IS Used for Review Severity of Illness Primary category FIELD FORM Alpha 2 Digit mm/dd/yy 1 =Male 2=Female mm/dd/yy X-Digit 1=PSP 2=HMO 3=Clinic Plan 4=Not enrolled Alpha Alpha Alpha Alpha ? Digits mm/dd/yy mm/dd/yy Up to 3 Digits 5-Digit 1=Yes 2=No 1=Yes 2=No 1=Adult 2=Child/Adolescent 1=Severe signs/symptoms 2=SeIf-care/functioning 3=Harm to self 4=Harm to Others 5=Drug/med complications 6=N/A Admission Not Certified TYPE FIELD FORM RETROSPECTIVE REVIEW DATA ELEMENT Code/Numeric Intensity of Service Admission Justified? Number of Days of Care Approved Number of Days of Care Denied Reasons for denial Numeric Numeric Numeric Coded/Numeric Date Decision was Communicated to Hospital RECONSIDERATION DATA ELEMENT Requested by (Name) Requested by (ID Number) Date of Request Reconsideration Conducted by Date Type of Reconsideration Date TYPE Character Numeric Date Character Date Coded/Numeric Decision Materials sent (provider, MSA, DCH) Appeal Filed Appeal Disposition Coded/Numeric Date Date Coded/Numeric C-112 Quality Improvement and Performance Monitoring Plan Appendix B - Inpatient Data Elements Page 21 1=Needed close/continued medical observation to make med changes 2=Need close/cts med obs to manage med side effects 3=Needs contin. observn to control behavior 4=Requires med. sup multi- modal bc plan due to complex/severe condition 5=N/A Admission Not Certified 1=Yes 2=No Up to 3 Digits Up to 3 Digits 1=Lacking Sufficient Documentation 2=Client Didn't Meet SI/IS Criteria During Denied Days mm/dd/yy FIELD FORM Alpha Digits (local) mm/dcVyy Alpha mm/dcVyy 1=Admission 2=Continuing Stay 3=Retrospective 1=Reconsid Denied 2=Reconsid Granted mm/dd/yy mm/dd/yy 1=Appeal Denied 2=Appeal Granted TYPE Date Time Coded/Numeric Character Character Character Character Numeric Character Numeric Date Coded/Numeric Numeric Quality Improvement and Performance Monitoring Plan Appendix B - PHP Data Elements Page 22 C-113 Appendix B - PHP Partial Hospitalization Review and Medicaid Authorization MINIMUM DATA REQUIREMENTS - DEFINITIONS Character Numeric Character Numeric Coded Numeric PRE-ADMISSION SCREENING DATA ELEMENT Date of Referral Time of Referral/Request Referral/Request Source CMH Clinical Screener (Name) CMH Clinical Screener (ID #) CMH Psychiatrist (Name) CMH Psychiatrist (ID #) Type of Admission Review Patient Name Address Street City State Zip County of Residence Name Code # Date of Birth Sex Medicaid # FIELD FORM mm/dd/yy hh/mm am or pm 1 =Self 2=Family 3=Physician/PSP 4=Psychiatrist 5=HospitaVER 6=Hospital/Inpatient 7=Hospital/PHP 8=Law enforcement 9=CMH program/staff 10=Other MH 1 1 =Other Alpha Digit (local) Alpha Digit (local) 1=Phone 2=Hospital face/face 3=CMH site face/face Alpha Alphanumeric Alpha Alpha 5-Digit Alpha 2 Digit mm/dd/yy 1=Male 2=Female X-Digit TYPE Coded/Numeric Character Character Character Coded/Numeric Character Coded/Numeric Coded/Numeric Coded/Number C-114' Quality Improvement and Performance Monitoring Plan Appendix B - PHP Data Elements Page 23 Coded/Numeric Numeric Numeric Character Numeric Character Numeric Date Character Date Numeric PRE-ADMISSION SCREENING DATA ELEMENT Medicaid Managed Care Plan(Level of Care) If PSP, Physician Sponsor Name If HMO, Name of HMO If Clinic Plan, Name of Clinic Plan Insurance Information: Other Primary Insurance? If Yes, Name of Other Primary Insurance Medicaid Potential CMH Status Other CMH Unique CMH Client Identifier CMH Case Manager Name CMH Case Manager ID Number Attending/Treating Physician Attending/Treating Physician ID Number Clinical Information: Last Psychiatric Hospitalization (admission) Hospital Name Discharge Date Diagnosis (DSM IV) Axis 1-Primary Axis 1-Secondary (Optional) Axis 2 Axis 3 Axis 4 Axis 5 SI/IS Used Level of Care SI/IS Used for Disposition FIELD FORM 1=PSP 2=HMO 3=Clinic Plan 4=Not enrolled Alpha Alpha Alpha 1=Yes 2=No Alpha 1=Spend-down 2=Dual coverage 3=Appears to meet Medicaid qualifications 1=Open 2=Closed 3=Never open in CMH County Code Digit (local) Alpha Digit (local) Digit (local) Digit (local) mm/dd/yy Alpha mm/dd/yy Five digit code(s) 1=Adult 2=Child/Adolescent 1=Inpatient 2=Crisis Residential 3=Partial Hospitalization 4=Crisis Stabilization TYPE Coded/Numeric Coded/Numeric Coded/Numeric Numeric Range 1-6 Depending Care Level Character Numeric Numeric Date Date Coded/Numeric Numeric Date Date Quality Improvement and Performance Monitoring Plan Appendix B - PHP Data Elements Page 24 C-115 Code/Numeric Date Time Coded/Numeric PRE-ADMISSION SCREENING DATA ELEMENT Severity of Illness Primary Category Secondary Category Substance Abuse Symptoms MR/DD Dual Diagnosis? Intensity of Services Admission Review Decision: Date/time of Decision PHP Admission approved Hospital: Name License # Phone # Date Admission Certification Sent to PHP Admission Date Expected attendance intensity Estimated Length of Stay Expected Discharge Date Next Review Date FIELD FORM 1=Severe signs/symptoms 2=SeIf-care/functioning 3=Harrn to self 4=Harrn to Others 5= Drug/med complicat NOTE: Recommend also identify SI/IS subcategory 1=Severe signs/symptoms 2=SeIf-care/functioning 3=Harm to self 4=Harrn to Others 5= Drug/med complicat 1=Yes 2=No 1=Yes 2=No 1 Digit mm/dd/yy hh/mm am or pm 1=Yes 2=No Alpha Digit 7 Digit mm/dd/yy mm/dd/yy 1=Full time 2=Part-time 2 Digit (# Days of stay) mm/dd/yy mm/dd/yy TYPE PRE-ADMISSION SCREENING DATA ELEMENT FIELD FORM Coded/Numeric Coded/Numeric Date Time Date Time TYPE Date Time Character Numeric Coded/Numeric Character Numeric Character Numeric Coded/Numeric Numeric Coded/Numeric C-116 Quality Improvement and Performance Monitoring Plan Appendix B - PHP Data Elements Page 25 Alternative Service Type of Program Communication: Contact with Other CMHSP Contact with primary physician/Health Plan CONTINUING STAY DATA ELEMENT Date of Review Time of Review CMH Reviewer Name CMH Reviewer ID Number Type of Review Hospital Name Hospital ID Number Hospital Person providing information Admitting Diagnosis Diagnosis Change? New Diagnosis Severity of Illness Status (Per SI/IS for Continuing Stay) 1=Yes 2=No 1=Crisis Residential 2=Crisis outreach 3=ACT 4=Other day program 5=Outpatient/CSM 6=Private MH provider 7=Substance abuse 8= Inpatient 9=Other mm/yy/dd hh/mm mm/dd/yy hh/mm FIELD FORM mm/yy/dd hh/mm am or pm Alpha Digit (local) 1=On-site at hospital 2=Phone Alpha ? Digit Alpha 5-Digit 1=Yes 2=No Five digit code(s) 1=Persistence of Condition 2=New Factors 3=N/A-Continuing Stay Not Approved TYPE FIELD FORM CONTINUING STAY DATA ELEMENT Date Coded/Numeric Coded/Numeric Coded/Numeric Numeric Coded/Numeric Numeric Coded/Numeric Date Time Date TYPE Date Numeric Numeric • Numeric Coded/Numeric C-117 Quality Improvement and Performance Monitoring Plan Appendix B - PHP Data Elements Page 26 Coded/Numeric Intensity of Service Status Estimated Discharge Date Consultation with CMH Supervisor? Consultation with CMH Psychiatrist Decision: Approved All Days of Care to Date Days Approved Denied Some/All Days of Care Days Denied Reasons for denial Date Decision was Communicated to Hospital Time of Decision Communicated to Hospital Next Review Date DISCHARGE REVIEW DATA ELEMENT Actual Discharge Date Days of Attendance Days Approved Medicaid Payment Authorization Number Discharge Plan 1=Receiving active tx according to an (PS 2=Tx reducing factors that necessitated admission 3=Progress toward goals or, if no progress, tx plan has been revised mrn/dd/yy 1 =Yes 2=No 1=Yes 2=No 1=Yes 2=No 2 Digit 1=Yes 2=No 2-Digit 1=Untimely Review 2=Lacking Sufficient Documentation 3=Client No Longer Meets SI/IS Criteria mm/dcVyy hh/mm am or pm mm/dd/yy FIELD FORM mm/dd/yy 2-Digit 2-Digit ? Digit 1=To Psych lnpt. 2=To CMH Cris Res/Stab 3=To Other CMH Services 3=To Private MH 4=To Sub. Abuse 5=Other TYPE RETROSPECTIVE REVIEW DATA ELEMENT FIELD FORM c-ue Quality Improvement and Performance Monitoring Plan Appendix B - PHP Data Elements Page 27 Date of Request Reason for Request Name of Other Insurance (if any) Attending Physician (Name) Attending Psychiatrist (ID #) Date of Retrospective Review Patient Name Address Street City State Zip County of Residence Name Code # Date of Birth Sex Date Retrospective Medicaid Eligibility Established Medicaid # Medicaid Managed Care Status • If PSP, Physician Sponsor Name If HMO, Name of HMO If Clinic Plan, Name of Clinic Plan Name of Hospital Requesting Retrospective Review Hospital ID Number Date of Patient Admission to PHP Date of Discharge from PHP Total Number of Days of Care Provided Date Coded/Numeric Character Character Numeric Date Character Character Character Character Numeric Character Numeric Date Coded/Numeric Date Numeric Coded/Numeric Character Character Character Character Numeric Date Date Numeric mm/dd/yy 1=Other lnsur. Exhausted 2=Retro Medicaid Eligibility 3=Other Alpha Alpha Digits mm/dd/yy Alpha Alphanumeric Alpha Alpha 5-Digit Alpha 2 Digit mm/dd/yy 1=Male 2=Female mm/dd/yy X-Digit 1=PSP 2=HMO 3=Clinic Plan 4=Not enrolled Alpha Alpha Alpha Alpha ? Digits mm/dd/yy mm/dd/yy Up to 3 Digits RETROSPECTIVE REVIEW DATA ELEMENT Admitting Diagnosis Axis 1 (Primary) Axis 1 (Secondary) Axis 2 Substance Abuse Symptoms MR/DD Dual Diagnosis? SI/1S Used for Review Severity of Illness Primary Category Intensity of Service Admission Justified? Number of Days of Care Approved Number of Days of Care Denied Reasons for denial Date Decision was Communicated to Hospital TYPE Numeric Coded/Numeric Coded/Numeric Coded/Numeric Coded/Numeric Code/Numeric Numeric Numeric Numeric Coded/Numeric Date Quality Improvement and Performance Monitoring Plan Appendix B - PHP Data Elements Page 28 C-119 FIELD FORM 5-Digit 1 =Yes 2=No 1 =Yes 2=No 1=Adult 2=Child/Adolescent 1=Severe signs/symptoms 2=SeIf-care/functioning 3=Harm to self 4=Harm to Others 5= Drug/med complica 6=N/A Admission Not Certified 1=Needed Intensive, structured, multimodal treatment 2=Finished lnpt Episode but Required Step-Down Care 3=Requires Medical Observation/Super to Regulate Medications 4=N/A Admission Not Certified 1=Yes 2=No Up to 3 Digits Up to 3 Digits 1=Lacking Sufficient Documentation 2=Client Didn't Meet SI/1S CRITERIA During Denied Days mm/dd/yy C-120' Quality Improvement and Performance Monitoring Plan Appendix B - PHP Data Elements Page 29 RECONSIDERATION DATA ELEMENT Requested by (Name) Requested by (ID Number) Date of Request Reconsideration Conducted by Date Type of Reconsideration Decision Decision communicated Appeal Filed Appeal Disposition TYPE Character Numeric Date Character Date Coded/Numeric Coded/Numeric Date Date Coded/Numeric FIELD FORM Alpha Digit (iocal)s mm/dd/yy Alpha mrn/dd/yy 1=Admission 2=Continuing Stay 3=Retrospective 1=Reconsideration Denied 2=Reconsideration mrn/d/yy mm/dd/yy 1=Appeal Denied 2=Appeal Granted C-121 MEDICAID MANAGED MENTAL HEALTH CARE Quality Improvement and Performance Monitoring Plan Appendix C - Required Reports Each CMH Board will be required to submit certain reports (specified in this document) to DCH regarding key performance dimensions of the managed care program. Reports must be submitted on a quarterly basis, the exceptions are the credentialling report which is due with the first quarter report and the provider satisfaction survey results which is due with the last quarter report. Quarterly reports must be sent to DCH within 30 days of the close of the quarter. All reports are to be submitted via disc together with one hard copy of the complete report. QUALITY INDICATOR REPORTS 1. Attributes of Care a. Application of Clinical Criteria • Inpatient Pre-Admission Screenings, Continuing Stay Reviews, Retrospective Reviews. • Partial Hospitalization Pre-Admission Screenings, Continuing Stay Reviews, Retrospective Reviews. b. CMH/Physician Coordination/Communication • Notification of inpatient and PHP screenings/reviews. • Notification of significant changes. c. Inpatient Recidivism within 15 Day Standard • Number of readmissions, readmission days of care, number of cases reviewed by hospital; Narrative on any trends and improvement plans developed. d. Out-of-state placements: Individual case information on admissions, days of stay, payments. e. Credentialling/privileging: Narrative on procedures and numbers of staff in each review activity category. 2. Appeals/Reconsiderations a. Recipient/Family Appeals/Complaints • Number, type, and resolution of CMH reconsiderations. b. Provider Appeals • Number, type, and resolution of inpatient pre-admission and continuing stay reconsiderations. • Number, type, and resolution of PHP admission and continuing stay reconsiderations. 3. Satisfaction a. Provider Satisfaction • Summary of annual provider satisfaction assessment (question set). Quality Improvement and Monitoring Plan Appendix C - Required Reports Page 31 C-122 MONITORING REPORTS 1. Utilization Reports a. Inpatient Use - Trend report on admissions, unique number of cases, days, admission rate, use rate. b. Partial hospitalization - Trend report on admissions, unique number of cases, days, admission rate, use rate. c. Crisis Residential -Trend report on admissions, unique number of cases, days, admission rate, use rate. d. Crisis Stabilization -Trend report on admissions, unique number of cases, days, admission rate, use rate. 2. Expenditure Reports a. Service activity and Medicaid payment liability compared to target: 1. Inpatient 2. Partial hospitalization 3. Crisis Residential 4. Crisis Stabilization 5. Total as compared to target b. Reviews and Related Activities - Payments compared to cap: 1. Inpatient (preadmission screening, episode management, retrospective reviews) 2. PHP (preadmission screening, episode management, retrospective reviews) 3. Total as compared to cap 4. Reconsiderations and appeals 5. Out-of-state placement reviews NARRATIVES Plans of Correction/Improvement: Narratives on improvement activity and impact on any QIPMP dimension that was out of compliance. FISCAL NOTE (Misc. 1197018) BY: FINANCE AND PERSONNEL COMMITTEE - SUE ANN DOUGLAS, CHAIRPERSON IN RE: OAKLAND COUNTY COMMUNITY MENTAL HEALTH FY 96-97 FULL MANAGEMENT CONTRACT WITH MICHIGAN DEPARTMENT OF COMMUNITY HEALTH To the Oakland County Board of Commissioners Chairperson, Ladies and Gentlemen: Pursuant to Rule XII-F of this Board, the Finance and Personnel Committee has reviewed the above-referenced resolution and finds: 1. The contract is between the Michigan Department of Community Health (DCH) and the County of Oakland for the period October 1, 1996 through September 30, 1997. 2. The total amount of gross funding in the contract is $150,369,322, with $8,460,425 in County match which is currently budgeted and requires no additional appropriation. The funding sources are detailed as follows: State Match $101,494,389 County Match 8,460,425 Federal Share of Medicaid 37,868,162 1st and 3rd Party Reimbursement 785,793 OBRA, Managed Care and Path Grant 1,607,094 IGT Transfer 50,881 Subtotal - CMH Fund $150,266,744 Federal Block Grant Funds 102,578 GRAND TOTAL $150,369,322 3. This contract has been approved by the Board of Commissioners Public Services committee. 4. The FY 1996/97 and 1997/98 Biennial budget shall be amended as stated in the resolution. FINANCE AND PERSONNEL COMMITTEE Aett C(ArvIA. tt D-7,(/ Lynn D. Allen, County Clerk : Resolution #97018 February 13, 1997 Moved by Taub supported by Amos the resolution be adopted. AYES: Millard, Moffitt, Obrecht, Pernick, Powers, Taub, Wolf, Amos, Coleman, Devine, Dingeldey, Douglas, Garfield, Holbert, Huntoon, Jacobs, Jensen, Johnson, Kaczmar, Kingzett, Law. (21) NAYS: McPherson. (1) A sufficient majority having voted therefor, the resolution was adopted. STATE OF MICHIGAN) COUNTY OF OAKLAND) I, Lynn D. Allen, Clerk of the County of Oakland, do hereby certify that the foregoing resolution is a true and accurate copy of a resolution adopted by the Oakland County Board of Commissioners on February 13, 1997 with the original record thereof now remaining in my office. In Testimony Whereof, I have hereunto set my hand and affixed the seal of the County of Oakland at Pontiac, Michigan this 13th day of February 1997.