Targeted Case Management Services

Transcription

1 Targeted Case Management Services 2013

2 Acronyms and Abbreviations AHCA Agency for Health Care Administration MMA Magellan Medicaid Administration CBC Community Based Care CBH Community Behavioral Health CSU Crisis Stabilization Unit CW Child Welfare DCF Department of Children and Families DJJ Department of Juvenile Justice 2

3 Acronyms and Abbreviations, cont. N/A Not Applicable NA Narcotics Anonymous NOS Not Otherwise Specified R/O Rule Out SRT Short-term Residential Facility CSU - Crisis Stabilization Unit TCM Targeted Case Management TCM Handbook - Florida Medicaid Mental Health Targeted Case Management Coverage and Limitations Handbook (Effective Date: June 2007) 3

4 Please Note This presentation is intended to be an overview of documentation requirements for the effective and quality delivery of Mental Health Targeted Case Management services. Its purpose is to act as a guide for providers to aid in compliance with pertinent documentation requirements and therefore may not cover ALL requirements. It is the provider s responsibility to review and continually utilize applicable state and/or federal rules, regulations, and contractual requirements. 4

5 Training Objectives Gain an increased understanding of the following Medicaid requirements: Medicaid enrollment Eligibility criteria for children under the age of 18 Eligibility criteria for adults 18 and older Eligibility criteria for mental health intensive case management team services Covered services Service restrictions Documentation requirements Common documentation concerns Common reasons for noncompliance 5

6 Resource Reference Florida Medicaid Mental Health Targeted Case Management Coverage and Limitations Handbook (Effective Date: June 2007) All Florida Medicaid Handbooks may be accessed on line at ( 6

7 Purpose and Goal of Service The purpose of mental health targeted case management is to assist individuals (recipients) in gaining access to needed medical, social, educational, and other services. The primary goal of mental health targeted case management is to optimize the functioning of recipients who have complex needs by coordinating the provision of quality treatment and support services in the most efficient and effective manner. Services and service frequency should accurately reflect the individual needs, goals and abilities of each recipient and must not simply reflect the Medicaid maximum allowable for the service. (TCM Handbook, Page 1-1) 7

8 Enrollment Providers must meet the general Medicaid provider enrollment requirements as contained in Chapter 2 of the Florida Medicaid Providers General Handbook. Mental health targeted case management agency providers are enrolled as a Provider Type 91, Case Management Agency. Mental health targeted case management supervisors are enrolled as Provider Type 32, Social Worker/Case Manager. 8

9 Enrollment, cont. A mental health targeted case management agency must enroll as a Medicaid group provider. The group must consist of at least one case management supervisor. A mental health targeted case management agency must enroll as a Medicaid provider in order to provide services to one or more specific target groups. (TCM Handbook, Page 1-3) 9

10 Target Groups To receive mental health targeted case management services, a recipient must be in one of the following specific target groups: Children s mental health targeted case management for recipients from birth through 17 years. Adult mental health targeted case management for recipients age 18 years and older. Intensive case management team services for recipients age 18 and older. (TCM Handbook, Page 1-2) 10

11 Enrollment, cont. Enrollment Period The effective date of enrollment is the date the provider application is received by the Medicaid fiscal agent. Medicaid does not enroll providers retroactively. A provider should not bill until it receives confirmation from Medicaid that it is enrolled in Medicaid, has received its Medicaid provider number, and confirmation of the effective date of the enrollment. Providers cannot bill for dates of service prior to the effective date of enrollment. (TCM Handbook, Page 1-4) 11

12 Certification Provider Agency Certification The area Medicaid office must certify the mental health targeted case management agency for the specific target group that the agency will serve. To be certified as mental health targeted case management agency, the agency must meet the Administrative and Programmatic certification criteria listed on page 1-6 of the TCM Handbook. A copy of the agency s certification must be signed by the area Medicaid office and submitted with the provider agency s enrollment application. 12

13 Certification Provider Agency Certification, cont. The provider agency must complete the required certification form specific to the target population(s) the agency will serve. The appropriate certification form must be signed and dated by the Provider Administrator and the Area Medicaid Office Designated Representative. All fee for service providers must have a fully executed certification form on file and all managed care organizations must ensure that all certification criteria are met. (Refer to Appendices B, C, and D, found on pages B-1, C-1 and D-1 of the TCM Handbook for copies of the certification forms). 13

14 Certification Supervisor Certification Criteria The provider agency administrator must certify case management supervisors upon enrollment for the target group the supervisor will serve. The provider agency must maintain the case management supervisor s certification forms on file. (Refer to Appendices E and F found on pages E-1 and F-1 of the TCM Handbook for copies of the certification forms.) 14

15 Certification, cont. Mental health targeted case manager supervisors must meet the following certification requirements: A masters degree from a accredited university or college with a major in counseling, social work, psychology, criminal justice, nursing, rehabilitation, special education, health education, or a related human services field and three years of full time or equivalent professional experience serving the target population; or A bachelors degree from a accredited university or college and five years of full time or equivalent professional experience serving the target population; and 15

16 Certification, cont. Bring to the position a previous mental health targeted case management certification or have at least five years experience with mental health case management. Each supervisor must complete AHCA approved mental health targeted case management training within three months of initially supervising case managers. If the training is not completed within three months, the provider agency must request that the Medicaid fiscal agent disenroll the supervisor. The provider agency cannot continue to bill Medicaid for services rendered by the case management supervisor or by case managers under the supervisor s supervision. 16

17 Certification, cont. Individual Mental Health Targeted Case Managers The mental health targeted case management provider agency must certify individual targeted case managers for the specific target group the case manager will serve. The provider agency must maintain the individual case managers certification forms on file. Medicaid will only reimburse for services provided by certified mental health targeted case managers under the supervision of Medicaidenrolled mental health targeted case management supervisor. 17

18 Certification, cont. To be certified as a children s or adult mental health targeted case manager, an individual must meet the following criteria: Have a bachelors degree from a accredited university or college with a major in counseling, social work, psychology, criminal justice, nursing, rehabilitation, special education, health education, or a related human services field (a related human services field is one in which major course work includes the study of human behavior and development) and have a minimum of one year of full time or equivalent experience working with the target population the mental health targeted case manager will serve, specifically children with serious emotional disturbances or adults experiencing serious mental illness; or 18

19 Certification, cont. Have a bachelors degree from a accredited university or college and three years of full time or equivalent experience working with the target population the mental health targeted case manager will serve specifically children with serious emotional disturbances or adults experiencing serious mental illness; Has completed or agrees to complete AHCA approved mental health targeted case management training within three months of initially providing Medicaid services. If the training is not completed within three months, the provider agency cannot continue to bill Medicaid for services rendered under the supervisor s Medicaid provider number. 19

20 Certification, cont. Have knowledge of available resources in the service area for the target population the mental health targeted case manager will serve; Is knowledgeable of and comply with state and federal statutes, rules and policies that affect the target population. (See Appendix G on page G-1 of the TCM Handbook for a copy of the Children s Mental Health Targeted Case Manager Certification form and Appendix H on page H-1 of the TCM Handbook for a copy of the Adult Mental Health Targeted Case Manager Certification form.) 20

21 Caseload Limitations Maximum average caseload limitations for Children and Adult Targeted Case Management services are as follows: Children s mental health targeted case management 20 recipients per each targeted case manager. Adults mental health targeted case management 40 recipients per each targeted case manager. If a mental health targeted case manager has a combined caseload, a child counts as two. The mental health targeted case manager must be certified to serve both target groups. (TCM Handbook, page 2-18) 21

22 Caseload Limitations, cont. Intensive Case Management Team Services The maximum average case load size for a team with four or more case managers shall be 15 persons per each team case manager. The maximum average case load size for a team with three case managers shall be seven persons per each team case manager. The maximum average case load size for a team with less than three case managers shall be six persons per each team case manager. (TCM Handbook, page 1-6) 22

23 Recipient Eligibility General Eligibility Requirement To receive mental health targeted case management services, the recipient must be Medicaid eligible on the date services are initiated and must be certified as meeting the eligibility criteria for a specific target group. Exceptions to Eligibility Requirements The following Medicaid recipients may receive mental health targeted case management for up to a maximum of 30 days without meeting the eligibility criteria for a specific target group: 23

24 Recipient Eligibility, cont. Exceptions to Eligibility Requirements, cont. A recipient who has been referred by Medicaid s contracted utilization management services vendor after a denied admission to or discharge from an inpatient psychiatric unit; A recipient who has been admitted to an inpatient psychiatric unit; or A recipient who has been identified by Medicaid s contracted utilization management services vendor as high risk. (TCM Handbook, Page 2-2) 24

25 Ongoing Eligibility The provider is responsible for ensuring ongoing eligibility. Justification of eligibility must be documented in the recipient s case record. If circumstances change and the recipient no longer meets eligibility criteria, Medicaid will no longer reimburse for mental health targeted case management services. 25

26 Certification Criteria for Children s Mental Health Targeted Case Management To initially certify any child, the provider must complete a Children s Mental Health Targeted Case Management Certification form within 30 days of the initial date of service. The certification form must be signed and dated by the mental health targeted case manager and that case manager s supervisor (See Appendix I on page I-1 of the TCM Handbook for a copy of the Children s Mental Health Targeted Case Management Certification form). Documentation must be provided in the child s case record indicating that the child meets all of the following criteria: Is enrolled in DCF s children s mental health target population (birth through 17 years); 26

27 Certification Criteria for Children s Mental Health Targeted Case Management, cont. Has a mental health disability (i.e., serious emotional disturbance) that requires advocacy for and coordination of services to maintain or improve level of functioning; Requires services to assist in attaining self-sufficiency and satisfaction in the living, learning, work, and social environments of choice; Lacks a natural support system for accessing needed medical, social, educational, and other services; Requires ongoing assistance to access or maintain needed care consistently within the service delivery system; 27

28 Certification Criteria for Children s Mental Health Targeted Case Management, cont. Has a mental health disability (i.e., severe and persistent mental illness) that, based upon professional judgment, will last for a minimum of one year; Is in out-of-home mental health placement or at documented risk of out-of-home mental health treatment placement; and Is not receiving duplicate case management services from another provider. If the recipient has relocated from a DCF district or region where and was receiving mental health targeted case management services, the recipient does not need to meet certification criteria. This must be documented in the recipient s case record. 28

29 Certification Criteria for Adult Mental Health Targeted Case Management To initially certify any adult recipient, the provider must complete a Adult Mental Health Targeted Case Management Certification form within 30 days of the initial date of service. The certification form must be signed and dated by the mental health targeted case manager and that case manager s supervisor (See Appendix J on page J-1 of the TCM Handbook for a copy of the Adult Mental Health Targeted Case Management Certification form). Documentation must be provided in the recipient s case record indicating that the recipient meets the following criteria: Is enrolled in a DCF adult mental health target population (18 years or older); 29

30 Certification Criteria for Adult Mental Health Targeted Case Management, cont. Has a mental health disability (i.e., severe and persistent mental illness) that requires advocacy for and coordination of services to maintain or improve level of functioning; Requires services to assist in attaining self-sufficiency and satisfaction in the living, learning, work, and social environment of choice; Lacks a natural support system for accessing needed medical, social, education, and other services; Requires ongoing assistance to access or maintain needed care consistently within the service delivery system; 30

31 Certification Criteria for Adult Mental Health Targeted Case Management, cont. Has a mental health disability (i.e., severe and persistent mental illness) that, based upon professional judgment, will last for a minimum of one year; and Is not receiving duplicate case management services from another provider; and Meets at least one of the following requirements: Is awaiting admission to or has been discharged from a state mental health treatment facility; Has been discharged from a mental health residential treatment facility; 31

32 Certification Criteria for Adult Mental Health Targeted Case Management, cont. Has had more than one admission to a CSU, SRT, inpatient psychiatric unit, or any combination of these facilities within the past 12 months; Is at risk of institutionalization for mental health reasons; or Is experiencing long-term or acute episodes of mental impairment that may put him/her at risk of requiring more intensive services. If the recipient has relocated from a DCF district or region where and was receiving mental health targeted case management services, the recipient does not need to meet certification criteria. This must be documented in the recipient s case record. 32

33 Certification Criteria for Intensive Case Management Team Services To initially certify any adult recipient, the provider must complete a Adult Mental Health Targeted Case Management Certification form within 30 days of the initial date of service. The certification form must be signed and dated by the mental health targeted case manager and that case manager s supervisor (See Appendix K on page K-1 of the TCM Handbook for a copy of the Adult Mental Health Targeted Case Management, Intensive Case Management Team Services Certification form). Documentation must be provided in the recipient s case record indicating that the recipient is enrolled in a DCF adult mental health target population (18 years and older) and meets at least one of the following requirements: Has resided in a state mental health treatment facility for at least six months in the past 36 months; 33

34 Certification Criteria for Intensive Case Management Team Services, cont. Resides in the community and has had two or more admissions to a state mental health treatment facility in the past 36 months; Resides in the community and has had three or more admissions to a CSU, SRT, inpatient psychiatric unit, or any combination of these facilities within the past 12 months; or Resides in the community and, due to a mental illness, exhibits behavior and symptoms that could result in long-term hospitalization if frequent interventions for an extended period of time are not provided. If the recipient has relocated from a DCF district or region where and was receiving mental health targeted case management services, the recipient does not need to meet certification criteria. This must be documented in the recipient s case record. 34

35 Covered Services The following services are covered for all mental health target groups: Conducting the assessment in accordance with the criteria outlined in this chapter. Developing the recipient s service plan in accordance with the criteria outlined in this chapter. Working with the recipient and the recipient s family to address issues related to implementation of the service plan (Services where the family is involved must clearly be directed to meeting the identified needs of the recipient). 35

36 Covered Services, cont. Assessing the effectiveness of the service plan in meeting the identified needs of the recipient. Linking and facilitating the recipient with appropriate services and resources identified in the service plan through referrals to reach desired goals. Advocating for the acquisition of services and resources necessary to implement the service plan by representing or defending recipients through direct intervention. Coordinating the delivery of services as specified in the service plan with the help of the recipient, the recipient s family, and the recipient s natural support system. 36

37 Covered Services, cont. Monitoring service delivery to evaluate the recipient s progress. Documenting mental health targeted case management activities in accordance with the documentation requirements in this chapter. Crisis Intervention/Support by assisting recipients in crisis in getting access to the necessary resources in order to cope with the situation. Case management services billed in conjunction with any Medicaid reimbursable service for the purpose of providing and communicating critical information that would assist the recipient (not to exceed two units per event). 37

38 Covered Services, cont. Arranging for and coordinating after care services upon discharge from a residential or inpatient facility when discharge planning is not covered by the facility s per diem. Participating in the recipient s individualized treatment plan development or individualized service plan review under the Medicaid community behavioral health services program (time billed must be clearly justified as time dedicated to the recipient). Providing mental health targeted case management services in preparation for a child s discharge (last 90 days) from Behavioral Health Overlay Services (BHOS). 38

39 Covered Services, cont. Conducting a clinical care Medicaid recipient staffing, in which the case manager is meeting with either the recipient s treatment team or one-onone with any of the following individuals: psychiatrist, psychiatric ARNP, physician, therapist, teacher, attorney, guardian ad litem, or any other professional who is directly serving the recipient. (TCM Handbook, Page 2-17) 39

40 Service Restrictions The following is a partial list of those restrictions that have been identified through the review process as problematic for providers. A complete list of service restrictions can be found in the TCM Handbook, pages 2-8 through Medicaid will not reimburse for provision of direct therapeutic medical or clinical services (e.g., checking blood pressure, measuring height and weight, or providing psychotherapy). Medicaid will not reimburse for performing administrative functions such as checking recipient eligibility or clerical duties. Medicaid will not reimburse for internal supervision between the mental health targeted case management supervisor and the mental health targeted case manager 40

41 Service Restrictions, cont. Medicaid will not reimburse for services provided to a recipient who does not have a written assessment and current service plan developed in accordance with the requirements as described on pages 2-12 through 2-16 of the TCM Handbook. Medicaid will not reimburse for unsuccessful attempts to contact the recipient; e.g., a home visit when the recipient is not at home, a phone call when the recipient does not answer, or leaving a message on voice mail, , or an answering machine. Medicaid will not reimburse for a targeted case manager simply being present during a face-to-face therapeutic activity. 41

42 Service Restrictions, cont. Medicaid will not reimburse mental health targeted case management provider agencies for transporting recipients. Reimbursement for travel is incorporated into the unit rate and may not be billed separately. 42

43 Assessment Requirements Each mental health targeted case management recipient must receive a thorough assessment completed by the recipient s mental health targeted case manager, which will serve as the basis for the development of the recipient s service plan. The assessment is a holistic review of the recipient s emotional, social, behavioral, and developmental functioning within the home, school, work, and community. The assessment must be updated annually. The case management assessment must be completed within the first 30 days that the recipient receives mental health targeted case management services, and prior to the development of the service plan. 43

44 Assessment Requirements, cont. The mental health targeted case manager must make at least one home visit prior to the completion of the assessment to evaluate the safety and well being of the recipient. The home visit should be conducted in the setting in which the recipient resides. If the mental health targeted case manager is unable to make a home visit, he must conduct a face-to-face interview in another setting. Written justification must be provided in the recipient s case record explaining why the home visit could not be made. The mental health targeted case manager and his supervisor must sign the written justification. 44

45 Assessment Requirements, cont. The assessment must include information from the following sources: The recipient; The agency or individual who referred the recipient for mental health targeted case management services; The recipient s family and friends (with appropriate consent); Other agencies that are providing services to the recipient; The school district (for recipients under the age of 18 who are still attending school); and Previous treating providers, including inpatient and outpatient treatment (If collateral information cannot be obtained, the mental health targeted case manager must provide written justification in the recipient s case record. 45

46 Assessment Requirements, cont. The assessment must include all of the following components: Presenting problem(s) and history, including the recipient s legal representatives and family s assessment of his situation ( with appropriate consent); Psychiatric and medical history including medications and side effects; Recipient s current and potential strengths; Resources that are available to the recipient through his natural support system; Recipient s school placement, adjustment and progress (if applicable); Recipient s relationship with his family and significant others; Identification and effectiveness of services currently being provided; 46

47 Assessment Requirements, cont. Assessment of the recipient s needs and functioning abilities in the following areas: Mental health maintenance and abstinence from substance abuse or use; Family support and family education; Educational, vocational, or job training; Housing, food, clothing, and transportation; Medical and dental service; Legal assistance; Development of environmental supports through support groups, peer groups, community services, friends, landlords, employers; and Assistance with establishing financial resources. 47

48 Assessment Documentation Requirements The following assessment documentation requirements must be met: The assessment must be an identifiable document in the recipient s case record. Supporting documentation e.g., copies of findings, evaluations, and discharge summaries) gathered to complete the assessment must be filed in the recipient s case record. The assessment must include documentation that the mental health targeted case manager made a home visit prior to the completion of the assessment or written documentation by the case manager with signoff by the case manager s supervisor, explaining why this requirement could not be met. The assessment must be reviewed, signed, and dated by the case manager s supervisor prior to the completion of the service plan. 48

49 Service Plan Requirements Each recipient must have an individualized service plan written within 30 days on initiation of services by his mental health targeted case manager or case management team. The service plan must contain measurable short and long-term goals for the recipient and must outline the comprehensive strategy for assisting the recipient in achieving these goals. The service plan must: Be an identifiable document; Be developed in partnership with the recipient and the recipient s parent, guardian, or legal custodian (if applicable); 49

50 Service Plan Requirements, cont. Describe the recipient s service needs and the activities that the mental health targeted case manager will undertake in partnership with the recipient; Contain measurable goals and objectives derived from the recipient s assessment; Have identified time frames for achievement of goals; Include the name of the individual or agency responsible for providing the specific assistance or services; Be consistent with the recipient s treatment plan(s); 50

51 Service Plan Requirements, cont. Be signed and dated by the recipient, recipient s legal guardian or custodian (if recipient under 18 year old), the mental health targeted case manager (must include title), and the mental health targeted case manager s supervisor (must include title); and Be retained in the recipient s record. 51

52 Service Plan Review Requirements Service Plan Review The service plan review is a process conducted to ensure that services, goals, and objectives continue to be appropriate to the recipient s needs and to assess the recipient s progress and continued need for mental health targeted case management services. The recipient s eligibility for continued mental health TCM services must be reevaluated during the service plan review. The activities, discussion and review process must be clearly documented. The recipient, the mental health TCM, and the TCM s supervisor must sign and date the service plan review. The service plan must be reviewed and revised as significant changes occur in the recipient s condition, situation, or circumstances, but no less frequently than every six months. Documentation of the service plan review must be recorded in the recipient s case record. 52

53 Documentation Requirements In addition to the general Medicaid record keeping requirements and the specific documentation requirements listed for each target group, the following documentation requirements apply to all mental health targeted case management services: The recipient s record must contain the certification form, assessment, service plan, service plan review(s), documentation of the home visit; Case manager s name, signature, title, and date. Photocopies signatures, stamped signatures, or signatures of anyone other than the person rendering the service are not acceptable; Recipient s name; Service provided; 53

54 Documentation Requirements, cont. Date of service; Services beginning and ending time on the clock (e.g., 2:07 p.m. to 3:53 p.m.); Location of the service; Updates when the recipient changes residence, enters or is discharged form an inpatient hospital or state mental hospital, experiences a significant change that impacts his life and support system, changes custody, changes educational placement, or changes employment; and 54

55 Documentation Requirements, cont Detailed case notes that: Clearly reflect how the case manager s efforts are linked to the services and goals in the recipient s service plan; Describe the recipient s progress or lack of progress relative to the service plan; If a substitute case manager provided the service, explain the circumstances requiring the provision of services by a substitute case manager. If more than one contact to a recipient is made in a day, all contacts should be summarized in one case note. 55

56 Units of Service Targeted case management services are reimbursed in time units. Each time increment is called a unit of service. Fifteen minutes equals one unit of service. If multiple units are provided on the same day, the actual time spent must be totaled and rounded to the nearest unit. If the minutes total ends in a 7 or less, round down to the nearest 15-minnute increment. If the minute total ends in 8 or more, round up to the nearest 15-minute increment. For example, 37 minutes is billed as two units of service; 38 minutes is billed as three units of service. (TCM Handbook, page 3-2) 56

57 Common Documentation Concerns Concerns with Signatures: Signatures and/or dates missing; Pre-printed dates; Illegible signatures; Illegible dates: Examples of compliant signatures: Jane Jones, BA Targeted Case Manager, 06/21/11 Robert Smith, MS, Targeted Case Manager Supervisor, 6/22/11 57

58 Common Documentation Concerns, cont. Missing case notes; Legible name, dated signature and title of individual rendering the service; Identification of recipient; Start and end time of service not documented; Missing the location of the service (i.e. office, home); Case note does not describe the case manager s efforts on behalf of the client. 58

59 Common Documentation Concerns, cont. Case notes: Case notes not documented on date service is rendered; Not summarizing multiple contacts on one case note for the same day of service; Time on the clock is not used when documenting start and end times; Incorrect application of, rounding, units of service; Service note does not justify and/or support the number of units billed to render the service. Service note does not support that a covered service was provide. 59

60 Common Documentation Concerns, cont. Assessments Absence of source information from referring agency or individual; Absence of psychiatric and medical history, including medications and side effects; Absence of documentation of home visit; Absence of dated signature of TCM Supervisor prior to development of the service plan. 60

61 Common Documentation Concerns, cont. Service Plan Objectives that are not measurable; Objectives are not client focused; Documenting objectives that are clinical in nature and not specific to targeted case management services; Documenting objectives that are not individualized to the client s needs as described in the assessment; Objectives that are repetitive across recipients; Missing signatures, dates and/or title or credentials; One staff member dating signatures for everyone. 61

62 Common Documentation Concerns, cont. Service Plan Reviews: Reviews that are not completed within the required time frame, of at least every 6 months or as significant changes in condition, situation or circumstances occur; Reviews that are not dated, signed by recipient, recipient s legal guardian or TCM, without written explanation for the absence; Review not signed and dated by TCM Supervisor; Reviews lack documentation of progress or lack thereof related to goals and objectives outlined in the service plan; 62

63 Common Documentation Concerns, cont. Service Plan Reviews, cont. Documenting progress as none, minimal progress, or moderate progress without describing what that means for the particular client as related to his/her individualized service plan goals and objectives. 63

64 Resources for Technical Assistance Your local area Medicaid office. Provider Education Service is also available through Magellan Medicaid Administration. Assistance is available via telephone and On-site training is available Referral form can be obtained from local area offices Magellan website. 64

65 Mental Health Targeted Case Management Services Thank you! Q & A 65