Medicaid Rehabilitation

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1 Medicaid Rehabilitation Option Quarter BH Webinar Training Carl Chrisman, Clinical Manager Magellan Health Services

2 Magellan Training: Medicaid Rehabilitation Option MRO ACT Day Rehabilitation Community Support Psych Res Rehab SPMI Magellan Health Services, Inc. 2

3 Service Definitions / Clinical Guidelines Yellow Book : Def-2006.pdf New Draft Guidelines: Chapter 35 Rehabilitative Psychiatric Services: e-471/chapter-35.pdf Magellan Health Services, Inc. 3

4 Medical Necessity Rehabilitative Psychiatric Services

5 Medical Necessity for Rehabilitative Psychiatric Services [C.35] Health care services which are medically appropriate and Necessary to meet the psychiatric rehabilitation needs of the client; Rendered in the most cost-efficient manner and type of setting appropriate for the delivery of the covered service; Consistent in type, frequency, duration of service with accepted principles of psychiatric rehabilitation; Consistent with the diagnosis of the condition; Magellan Health Services, Inc. 5

6 Required for means other than convenience of the client or his or her service provider(s); No more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness, and efficiency; Of demonstrated value; and A no more intense level of service than can be safely provided. For the purpose of this Chapter, rehabilitative psychiatric services are medically necessary when those services can reasonably be expected to increase or maintain the level of functioning in the community of clients with severe and persistent mental illness. Magellan Health Services, Inc. 6

7 SPMI Defined The Nebraska Medical Assistance Program (NMAP) covers rehabilitative psychiatric services to rehabilitate clients experiencing severe and persistent mental illnesses in the community

8 SPMI At risk of institutionalization if services not provided Seriously interferes with functioning Has had one year or will have Results in significant functional limitations in two of three life skills areas. Not primary substance abuse Not primary developmental disabilities Magellan Health Services, Inc. 8

9 Functional Limitations SPMI and Life Skills Training Needs

10 Vocational/Education Functional limitations in the area of Vocational/Education abilities are defined as: (1) An inability to be consistently employed or an ability to be employed only with extensive supports, except that a person who can work but is recurrently unemployed because of acute episodes of mental illness is considered vocationally impaired; (2) Deterioration or decompensation resulting in an inability to establish or pursue educational goals within a normal time frame or without extensive supports; (3) An inability to consistently and independently carry out home management tasks, including household meal preparation, washing clothes, budgeting, and child care tasks and responsibilities; Magellan Health Services, Inc. 10

11 Social Skills Functional limitations in the area of Social Skills and abilities are defined as: (1) Repeated inappropriate or inadequate social behavior or an ability to behave appropriately or adequately only with extensive or consistent support or coaching or only in special contexts or situations, such as social groups organized by treatment staff; or (2) Consistent participation in adult activities only with extensive support or coaching and when involvement is mostly limited to special activities established for persons with mental illness or other persons with interpersonal impairments; or (3) A history of dangerousness to self or others. Magellan Health Services, Inc. 11

12 Activities of Daily Living Functional limitations in the area of Activities of Daily Living are defined as an inability to consistently perform the range of practical daily living tasks required for basic adult functioning in the community, in three of five areas listed below: (1) Grooming, hygiene, washing of clothes, and meeting nutritional needs; (2) Care of personal business affairs; (3) Transportation and care of residence; (4) Procurement of medical, legal, and housing services; or (5) Recognition and avoidance of common dangers or hazards to self and possessions. Magellan Health Services, Inc. 12

13 Initial Auth What information do I need when I call Current diagnosis (onset) What led to the referral (why now) Rehabilitation Assessment Strengths Functional Limitations across life skills area Rehabilitation Treatment Goals Licensed clinician contact Client demographics Service location Admission Criteria Magellan Health Services, Inc. 13

14 Magellan Notes CALLER DEMOS:: [?NAME/PHONE/LOC/MH/SA/STATEWARD/GUARDIAN/ELOS/SP/AD MIT DATE] ACT, DR, PRR, CS; Estimated Length of Stay (based upon estimated time it will take to meet goals); admit date PRESENTING PROB:: [?CONSUMER WORDS/PROVIDER UNDERSTANDING/FAMILY EXPLANATION] The presenting problem is needed for IP and sub acute. For DR, ACT, CS there may or may not be specific presenting problem. The Why Now section will capture proximal events and the client s personal perspective on the need for the service. WHY NOW:: [?SPECIFIC REASON/NOW VERSUS LAST MONTH/WHAT IS IMPORTANT] By asking what the client would like to gain from the service and what is important to them we are getting to why now. Often why now is in the referral information, i.e., frequent hospitalizations, homelessness due to mental illness, etc. Magellan Health Services, Inc. 14

15 MSE:: [?TRAUMA/SO/ORIENTED/BEHAVIOR/AFFECT/THOUGHTS] It is important to determine if the client is at base line or is having acute symptoms in order to recommend the right service. Trauma history is included here. RISK:: [?SI/HI/PLAN/MEANS/HX/PREGNANT/SUBSTANCE ABUSE] Current risk for harm to self or others. If a history of dangerousness what are the risk factors or triggers. Is substance abuse a risk factor? PERSONAL STRENGTHS:: [?INSIGHT/COPING SKILLS/MOTIVATION] Include motivation, achievements, interests, hobbies, skills, etc. Magellan Health Services, Inc. 15

16 FUNCTIONAL IMPAIRMENTS:: [?ADL/ED/VOC/SOC/REC/SPECIFICS/SPECIAL NEEDS] Significant functional limitations in two of three life skills areas are needed to meet the required SPMI criteria. These are identified via a functional or rehabilitation assessment. Good idea to list them in the appropriate life skill area. SUBSTANCE ABUSE:: [?SEARCH 219 ASAM CRITERIA] F9 = Search ASA Services only. DIAGNOSIS:: [?SPMI/SED/AXISI-V] NOS diagnoses are not generally acceptable here. Magellan Health Services, Inc. 16

17 MEDICAL CONCERNS:: [?VITALS IF WITHDRAWING/PREG/MED/NEURO/ISSUES] Be sure to have information from the most recent health screen or physical. CURRENT MEDICATION:: [?COMPLIANT/ALL MEDS] Do we know if the client is compliant with psychotropic medication? If not, how can MRO services support this in the treatment plan. FAMILY/COMMUNITY SUPPORT:: [?PEER/FRIENDS/CHURCH/FAMILY/RELATIVES] Natural supports section. These involvements need to be nurtured, as appropriate, as they can become part of the rehab and discharge plan.tx HISTORY/PREVIOUS SOLUTIONS:: [?SUCCESSES/SERVICE COMBINATIONS/ETC] Do we know of service combinations that were successful? Where there extended periods where the client was not hospitalized? Can we identify any conditions which supported this? Magellan Health Services, Inc. 17

18 LEGAL HISTORY:: [?MHB/CURRENT STATUS] MHB commitments? Legal charges, court orders, etc. ICM:: [?FORMER/PRESENT/REFER] ICM is a Magellan program with specific admission criteria. CASE MANAGEMENT/OP PROVIDER:: [?CS/OP THERAPY/PSYCHIATRIST/OTHER] Who is are the current providers, who need to coordinate treatment with each other. PCP:: [?PCP INVOLVED/NOTIFICATION REQUESTED] Does the client have a primary care physician? If not, can one be located? Magellan Health Services, Inc. 18

19 TX PLAN:: [?HOW IS WHY NOW ADDRESSED/TOP GOALS/TRAUMA ADDRESSED] Initial Rehab goals related to the assessed functional limitations. What are the client s goals? Is trauma being addressed, maybe by another provider. DC PLAN:: [?DC PLAN/SA/OP PROVIDER/HOW WILL WHY NOW BE ADDRESSED/MRO/NURSING] Initial d/c plan, ideas regarding supports that will be necessary when service goals are met. OTHER:: [?QUALITY OF CARE CONCERNS/FAMILY CAREGIVER NEEDS/LINKAGES] Are there referrals and/or assessments which need to be made? Magellan Health Services, Inc. 19

20 DISPOSITION:: [?MED NEC MET/NOT MET/RATIONALE/PHYSICIAN REVIEW] Guidelines met or if not met, why? If not met, the care manager will take to our medical director for review. CM ACTION:: [?NEXT REVIEW ITEMS/HOMEWORK/RX PLAN ADJ/TRANSPORTATION] Date of next review. Is there any additional information which will need to be reviewed? Does the client require transportation? Etc. Magellan Health Services, Inc. 20

21 Re-Auth Client Name and SS# Agency Name and Contact Person Auth End Date Medications Current Dx Program Type or Service Medicaid ID# and Service Location Magellan Health Services, Inc. 21

22 MRO Re-Auth Form Rehabilitation Needs Measureable Goals Progress on Goals Crisis Plan (include something other than ER or 911) Discharge Plan and ELOS Hospitalizations or ER visits in report period Psychiatrically Stable (if not a brief description) Specific Functional Limitations R/T Major Mental Health Diagnosis Magellan Health Services, Inc. 22

23 Magellan Health Services, Inc. 23

24 Service Fit Client Need and Service Selection

25 ACT High utilization of emergency/hospital services Spikes in acuity Poor response to lower levels of care Traditional approaches not successful Can live independently 24 hour available urgent intervention Poor response to other treatment Magellan Health Services, Inc. 25

26 Psychiatric Residential Rehab Locus: Functional limitations require training which is best done in a residential setting Focus: And 24 hour per day on-site behavioral intervention and residential social and ADL programming Magellan Health Services, Inc. 26

27 Day Rehab Locus: Need is best met in a structured day program Focus: Life Skills training in all skills areas Magellan Health Services, Inc. 27

28 Community Support Locus: In home Focus: Case Management and Self Care Magellan Health Services, Inc. 28

29 Considerations

30 Considerations A major mental illness alone is not sufficient for SPMI Presence of symptoms is not sufficient Provider must link functional deficits to Axis I disorder NOS not acceptable Disability Magellan Health Services, Inc. 30

31 Considerations Brain injury DD Substance Abuse Medical/Physical issues Magellan Health Services, Inc. 31

32 MRO Exclusion Not SPMI Primary Diagnosis is substance abuse or DD Does not have functional deficits in two or three areas Resides in a Nursing Home Needs a higher LOC Magellan Health Services, Inc. 32

33 MRO Discharge Maximum benefit Sustainability plan in place Supports in place Crisis relapse plan in place Or the individual requests discharge Magellan Health Services, Inc. 33

34 Magellan Health Services, Inc. 34

35 Question & Answer

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