Mental Health Case Manager and Thse Duties

Transcription

1 Adult Mental Health March 2012 CASE MANAGEMENT Tennessee Department f Mental Health In Cllabratin with the Bureau f TennCare echappelltdmhresearchteam (March 27, 2012) Page 1 f 50

2 Acknwledgments E. Duglas Varney Cmmissiner, Tennessee Department f Mental Health (TDMH) Marie Williams, LCSW Deputy Cmmissiner, TDMH, and C- Executive Editr Hward Burley, Jr., MD Chief Medical Directr, TDMH, and Executive Editr Marthagem Whitlck, MSW Assistant Cmmissiner, TDMH, Divisin f Planning, Research, and Frensics Rdney Bragg, MA, MDiv Assistant Cmmissiner, TDMH, Divisin f Alchl and Drug Abuse Services Gwen Hamer, MA, CPC Directr f Educatin and Develpment, TDMH, Clinical Leadership Melissa Sparks, MSN, RN Directr f Crisis Services, TDMH, Mental Health Services Edwina Chappell, PhD Research Team, TDMH, Divisin f Planning, Research, and Frensics Bureau f TennCare Tennessee Department f Finance and Administratin Special Thanks Case Management Sciety f America (CMSA) fr allwing the use f their Standards f Practice fr Case Management in the writing f this dcument. Thmas Beatty, Kentucky (KY) Divisin f Behaviral Health, Department fr Behaviral Health, Develpmental and Intellectual Disabilities Carl LaBine, Adult Mental Health Divisin, Minnesta (MN) Department f Human Services Richard Seurer, MN Department f Human Services Bill Cleman, Dakta Cunty (MN) Scial Services Duglas Ruderman, New Yrk State Office f Mental Health Keith Breswick, Oregn Health Authrity, Mental Health Services, Addictins & Mental Health Divisin Tennessee Assciatin f Mental Health Organizatins (TAMHO) Tennessee Managed Care Organizatins (MCOs): AmeriChice by UnitedHealthcare; Amerigrup Tennessee, Inc.; and ValueOptins, Inc. Page 2 f 50

3 Table e f Cntents Page Acknwledgments Table f Cntents Mental Health Case Management (MHCM) Tennessee Definitins Case Management What Is Case Management? Are There Multiple Case Management Mdels? Adult Mental Health Case Management (MHCM) Tennessee What Will Adult Mental Health Case Management (MHCM) Include in Our State? Examples f the Primary Duties f an Adult Mental Health Case Manager and Thse Duties That Are Nt Cnsidered the Respnsibility f a Case Manager Benefit Limitatins n Adult MHCM- Tennessee What Is the Criteria fr Medical Necessity? Wh Will Determine Medical Necessity? What Are the Principles Underlying Adult MHCM- Tennessee? Wh Can Receive Adult MHCM- Tennessee Services? Will All Eligible Service Recipients Receive the Same Level f Adult MHCM- Tennessee Services? Level 1 Adult MHCM- Tennessee Team Intensive Services Level 2a Adult MHCM- Tennessee Individual Intensive Services Page 3 f 50

4 Page Level 2b Adult MHCM- Tennessee Individual Supprtive Services Hw Lng Will It Take Eligible Service Recipients t Begin Receiving Adult MHCM- Tennessee Services? Adult MHCM- Tennessee Service Delivery Prcess Case Management Staff/Prvider Requirements Case Manager Requirements Level 1 Adult MHCM- Tennessee Team Intensive Services Level 2a Adult MHCM- Tennessee - Individual Intensive Services Level 2b Adult MHCM- Tennessee Individual Supprtive Services Supervisr Requirements Outcmes Level 1 Adult MHCM- Tennessee Team Intensive Services Level 2a Adult MHCM- Tennessee Individual Intensive Services Level 2b Adult MHCM- Tennessee Individual Supprtive Services Assessment Tls fr Case Managers Research n the Benefits f Case Management Supprtive Mental Health Case Management: A Case Study References Page 4 f 50

5 Mental Health Case Management (MHCM) Tennessee All mental health statutes are incrprated within Title 33 f the Tennessee Cde Anntated (TCA). Chapter 1, Part 2 specifically designates the Tennessee Department f Mental Health (TDMH) as the State s mental health authrity. As such, TDMH has respnsibility fr system planning, system mnitring and evaluatin, setting plicy and quality standards, disseminating infrmatin t the public, and advcacy fr all persns, regardless f age, that have a mental illness r serius emtinal disturbance. The Department s missin incrprates planning fr and prmting the availability f a cmprehensive array f quality preventin, early interventin, treatment, habilitatin and rehabilitatin services and supprts based n the needs and chices f individuals and families served (TDMH Web page). Case management, specifically mental health case management (MHCM), is ne f many effective services prmted by TDMH because it strives t cnnect persns with mental illness t needed resurces and services that prvide fr recvery, self sufficiency, and an verall better quality f life. Definitins Behaviral Health Safety Net f TN (BHSN f TN) An assistance fr uninsured service recipients in the State f Tennessee that have been classified in the pririty ppulatin and require behaviral health services n an utpatient basis. Eligibility is predetermined and must be met fr service recipients t qualify fr this assistance. Eligibility criteria include Tennessee residency, United States citizenship, incme at 100 percent f the federal pverty level, and lack f ther insurance r payr surce (TDMH, January 2009). Bureau f TennCare The divisin f the Tennessee Department f Finance and Administratin that has been designated and apprved t administer the TennCare prgram (CRA, 2011). Health Maintenance Organizatin (HMO) An entity certified by the Tennessee Department f Cmmerce and Insurance (TDCI) under applicable prvisins f TCA Title 56, Chapter 32 (CRA, 2011). Diagnstic and Statistical Manual f Mental Disrders (DSM) Published by the American Psychiatric Assciatin, this manual prvides cmmn language and standard criteria fr the classificatin f mental disrders. Criteria fr a diagnsable mental disrder shuld be based n the mst current revisin. Page 5 f 50

6 Managed Care Organizatin (MCO) an entity licensed t perate as a Health Maintenance Organizatin (HMO) in the State f Tennessee that has met additinal qualificatins established by the State fr prviding r arranging fr the prvisin f cvered physical health, lng- term care, and behaviral health services t persns enrlled in the TennCare prgram and fr whm it has received prepayment (adapted frm CRA, 2011). Medically Necessary A requirement fr a medical item r service t be paid fr by TennCare. Criteria, herein identified as medical necessity is delineated in this dcument. Prvider An agency r facility apprved by TDMH that accepts payment fr prviding services t an eligible BHSN r TennCare service recipient (TDMH, January 2009). Families First Tennessee s versin f the Temprary Aid t Needy Families (TANF) prgram, a federal- state cash assistance prgram. Basic rules fr administratin are set by the federal gvernment, but states have respnsibility fr develping their prgrams and incme eligibility limits. Benefit levels fr the State f Tennessee are set by ur state. Such levels vary widely acrss states (TDHS, 2011). TennCare The Medicaid prgram in the State f Tennessee that perates thrugh the Tennessee Department f Finance and Administratin, Bureau f TennCare, as designated by the State and the Centers fr Medicare and Medicaid Services (CMS) pursuant t Title XIX f the Scial Security Act and the Sectin 1115 Research and Demnstratin waiver granted t the State f Tennessee (CRA, 2011). Tennessee Department f Cmmerce and Insurance (TDCI) The state agency with the statutry authrity t regulate, amng ther entities, health maintenance rganizatins and insurance cmpanies (CRA, 2011). Tennessee Department f Finance and Administratin In additin t being the single state Medicaid agency, this state agency versees all state spending and acts as the chief crprate ffice f the state (CRA, 2011). Veteran s Administratin Benefits The Department f Veterans Affairs prvides a definitin f Disabled Veterans with a Mental Illness. The disability has t be within the purview f the VA s definitin f mental disability, which is based n the DSM- IV- TR criteria. If determined eligible, benefits are available. Case Management Case management is tl that has been used acrss varied disciplines, in varied settings, by varied prfessinals. In the wrld f behaviral health, case management is used t crdinate service delivery fr persns with mental illness while ensuring cntinuity and integratin f services (DHHS, 1999). It has emerged as an imprtant interventin in the Page 6 f 50

7 field because it maintains a cnsistent and primary fcus n client self- determinatin and quality f care while fstering the careful shepherding f health care dllars (CMSA, 2010). After deinstitutinalizatin, thusands f mentally ill individuals were mved frm the state psychiatric hspitals int the cmmunity fr service. Increasingly persns with mental illness were never even admitted t the state hspitals and the cmmunity mental health systems became mre cmplex and extremely difficult t navigate. Case management became a remedy t the cnfusin that was created by the multiple care prviders in varius settings. The interventin was further designed t ensure accessibility, accuntability, and cntinuity f care fr persns with lng- term disabling mental disrders (Encyclpedia f Mental Disrders, 2011). What Is Case Management? There are as many definitins f case management as there are grups r rganizatins that prvide r certify the service. Fr example, CMS defines case management as services that assist individuals eligible under the plan in gaining access t needed medical, scial, educatinal, and ther services, as added by the Deficit Reductin Act f 2005 (CMS, 2007). The Natinal Assciatin f Scial Wrkers (NASW) prvides a definitin fr case management that is mre prfessin specific and reads: Case management is a methd f prviding services whereby a prfessinal scial wrker assesses the needs f the client and the client s family, when apprpriate, and arranges, crdinates, mnitrs., evaluates, and advcates fr a package f multiple services t meet the specific client s cmplex needs. The Natinal Assciatin f State Mental Health Prgram Directrs (NASMHPD) has defined case management as a range f services prvided t assist and supprt patients in develping their skills t gain access t needed medical, behaviral health, husing, emplyment, scial, educatinal, and ther services essential t meeting basic human services; linkages and training fr patient served in the use f basic cmmunity resurces; and mnitring f verall service delivery (NASMHPD, 2011). One f the mst succinct yet cmprehensive definitins f case management is prvided by the Case Management Sciety f America (CMSA). CMSA defines case management as a cllabrative prcess f assessment, planning, facilitatin and advcacy fr ptins and services t meet an individual s and family s cmprehensive health needs thrugh cmmunicatin and available resurces t prmte quality cst- effective utcmes (CMSA, 2010, p. 6). Thus, the fcus includes nt nly individuals, but their natural supprts. Case management is an activity that assists individuals in gaining access t necessary medical, behaviral, scial, and ther services that are apprpriate t their needs. The service is nt nly individualized, but it is empwering, cmprehensive, persn centered, strengths- based, and utcme- fcused (Nrth Carlina Divisin f Medical Assistance, Mental Health, Everybdy benefits when individuals with mental health issues reach their ptimal level f wellness and functinal capability. Case management is ne f the means thrugh which Page 7 f 50

8 such persns can achieve wellness as well as ptimum functining. Case management service delivery can be individually based r handled by a team. It is prvided by individuals knwn as case managers, especially n the individual service- delivery level. As with mst strategies, there are guiding r clarifying principles. CMSA has identified 12 principles that guide the practice f case management: Case managers: 1. Cnnect with cmmunity resurces. 2. Assist in the navigatin f the health care system t achieve successful care, especially during transitins. 3. Prmte ptimal safety fr the cnsumers they serve. 4. Prmte the utilizatin f evidence- based care. 5. Prmte quality utcmes and the measurement f thse utcmes. 6. Prmte the integratin f behaviral change principles and science. 7. Use a hlistic, cmprehensive apprach. 8. Use a cllabrative, client- centric partnership apprach. 9. Practice cultural cmpetence, with respect fr and awareness f diversity. Accmmdatin fr diversity, gender, ethnicity, race, life stage, disability, and sexual rientatin shuld be build int the case management prcess. The five (5) elements assciated with becming culturally cmpetent include: valuing diversity; understanding the dynamics f cultural interactin; incrprating cultural knwledge; making/taking a cultural self assessment; and adapting practices t the diversity present in a particular setting (Why Case Management, 2000). 10. Facilitate self- care and self- determinatin thrugh the tenets f shared decisin- making, advcacy, and educatin, whenever pssible. 11. Maintain cmpetence in practice and pursue prfessinal excellence. 12. Maintain and supprt cmpliance with federal, state, lcal, rganizatinal, and ther relevant rules and regulatins (CMSA, 2010). Depending n case manager requirements fr a state r managed care rganizatin (MCO), fr example, case manager rles culd be varied. Individuals hired as case managers in the delivery f Adult MHCM- Tennessee services, hwever, will nt have blurred r verlapping rles. They will nt diagnse r prvide mental health treatment, fr example. Adult MHCM- Tennessee case managers will nly deliver case management services. As riginally designed, case management was nt a time- limited service. The intent was that service wuld be nging, ensuring that service recipients have whatever they need whenever they need it and fr as lng as they need it (Encyclpedia f Mental Disrders, 2011). Hwever, the idea f recvery suggests that peple can and d get better. They can functin independently. They can attain their gals. They can be cmpliant with their medicatins. They can hld dwn a full- time jb. They can mnitr their wn bld sugar. They can secure and maintain husing. Being able t be self- determined and self- reliant ring thrugh the mental health recvery definitin frm the Substance Abuse and Mental Health Services Administratin (SAMHSA): Mental health recvery is a jurney f healing Page 8 f 50

9 and transfrmatin enabling a persn with a mental health prblem t live a meaningful life in a cmmunity f his r her chice while striving t achieve his r her full ptential (SAMHSA, 2004). With the aid f case management, cnsumers shuld be able t accmplish the fllwing gals: 1. Increase their retentin in and cmpletin f treatment in rder t mve them tward recvery and self sufficiency. 2. Increase their access t essential services such as psychiatric care, primary health care, stable and secure living arrangements, psitive supprt netwrks, vcatinal and/r educatinal training, and emplyment (Adapted frm Pennsylvania Department f Health, 2003). Are There Multiple Case Management Mdels? A review f the literature typically yields tw mdels f case management. They are assertive cmmunity treatment (ACT) and intensive case management. Anther cmmnly referenced mdel is that f clinical case management (CCM). In this mdel, the case manager perfrms case management activities in additin t functining as the primary therapist/clinician. In CCM, case managers are expected t pssess necessary educatin and skills t perate as therapists (Mueser, Bnd, Drake, & Resnick, 1998). Then there is the blended case management mdel. It has been prmted recently by sme states in their effrts t help eligible individuals with mental illness gain access t needed medical, educatinal, scial, and ther services with minimal cmplexity (Pennsylvania Department f Public Welfare, 2009). The Assertive Cmmunity Treatment (ACT) mdel was first implemented at Mendta State Hspital in Madisn, WI, inside an inpatient research unit in the late 1960s. The underlying philsphy was t create and prvide a hspital withut walls. The mdel typically invlves a multidisciplinary team f prfessins that include case managers as well as medical and ther mental health prfessinals. This team has respnsibility fr a caselad f arund 10 cnsumers with mental health issues 365 days a year, seven (7) days a week, 24 hurs a day (DHHS, 1999). An emphasis is placed n helping the cnsumer t manage his/her wn illness and, with assistance as necessary, cnduct activities f daily living (Encyclpedia f Mental Disrders, 2011). ACT invlves a team apprach t delivering effective and cmprehensive services t adults diagnsed with severe mental illness and wh have needs that have nt been well met by mre traditinal appraches t delivering services. Amng the ACT principles are: 1) Engagement f individuals in treatment and mnitring; 2) The prvisin f a flexible and cmprehensive range f treatment and services; 3) Sharing f respnsibility between individuals and team members served by the team; 4) Targeted services fr a specific grup f individuals with severe mental illness; Page 9 f 50

10 5) Individualized treatment, rehabilitatin and supprt services; 6) Treatment, rehabilitatin and supprt services are prvided directly by the ACT team; 7) There are small staff t individual ratis (apprx. 1 t 10); 8) Interventins ccur in cmmunity settings rather than in clinic settings r hspitals; 9) Services are available twenty- fur (24) hur a day; AND 10) There is n arbitrary time limit n receiving services (CRA, 2011). The research base supprting ACT is verwhelmingly strng, with reprts f cntrl f psychiatric symptms, increased husing stability, reduced hspitalizatins and hmelessness, reduced inapprpriate hspitalizatins, and imprved quality f life (Encyclpedia f Mental Disrders, 2011). The Prgram f Assertive and Cmmunity Treatment (PACT) was develped by Stein and Test in the 1970s (Mueser, Bnd, Drake, & Resnick, 1998). It cntains the elements f ACT as a service delivery mdel fr prviding cmprehensive cmmunity- based treatment t adults with mental illness. It incrprates the use f a multidisciplinary team f mental health prfessinals rganized as an accuntable, mbile mental health agency r grup f prviders. Services are prvided in the cnsumer s wn hme r in an agreed upn lcatin in the cnsumer s cmmunity. PACT staff are similar t staff the cnsumer wuld encunter had he/she been hspitalized. They functin interchangeably as a team t prvide the treatment, supprt services, and rehabilitatin that persns with severe and/r persistent mental illnesses need t live successfully in the cmmunity (CRA, 2011) PACT takes the services prvided in the hspital hme, at least t the cmmunity. This strategy was cnceptualized when frmer psychiatric hspital patients began t lse grund after the rund- the- clck care f the hspital was n lnger available t the cnsumer fllwing discharge. In 1972, researchers mved the hspital- treatment staff int the cmmunity fr the real test. In PACT, the cnsumer des nt have the requirement f adapting t r fllwing prescriptive rules f a treatment prgram (NAMI, 2011). Unlike ACT and PACT, Intensive Case Management (ICM) is individually based and generally targeted t thse with the greatest needs. Fr example, individuals with a histry f multiple hspitalizatins r wh are bth hmeless and severely mentally ill wuld be assigned t ICM. It is mre likely that ICM case managers will schedule r cnnect clients with services rather than prvide them directly themselves. ICMs are strengths based and empwer cnsumers t fully participate in all treatment decisins (Encyclpedia f Mental Disrders, 2011). These strengths- based mdels peratinalize recvery principles while simultaneusly helping peple reclaim, recver, and transfrm their lives thrugh the identificatin and sustaining f a range f resurces fr thriving in the cmmunity (AMHD, 2008). Clinical case management (CCM) mdels tend t shw their greatest effect after cnsumers have been hspitalized. Underging CCM versus ACT tends t get the cnsumer ut f the hspital sner. Experts agree, hwever, that high- quality CCM and ACT shuld be Page 10 f 50

11 essential features f any mental health service system (Encyclpedia f Mental Disrders, 2011). Blended case management has been prmted as a case management mdel in which individuals with mental illness are nt required t change case managers when the intensity f their service needs changes. Pilted in the state f Pennsylvania, fr example, the mdel des nt alter the case management services being delivered, but there are changes in the manner in which such services are delivered. It allws the case manager, wh is referred t as the blended case manager, t make adjustments t service intensity based n the cnsumer s needs. In Pennsylvania, this pilt prject was initiated by the Office f mental Health and Substance Abuse Services in July Prject results demnstrated that blended case management: Increased cntinuity f care at bth the individual and systems levels; Decreased disruptin in service, thus allwing cnsumers and their families t fcus mre n gals; Allws services t be cnsumer driven; Gives the cnsumer as well as the case manager a greater sense f accmplishment because f the pprtunity t maintain a wrking relatinship thrugh transitins; AND Prvides flexibility, particularly fr individuals cming ut f facilities (Pennsylvania Department f Welfare, 2003). Case management mdels can be categrized in many different ways. Mrever, many f the same activities can be fund acrss mdels. Fr example, mst mdels prvide services fr the cnsumer in the cmmunity rather than in the ffice. The cmmn gal acrss case management mdels is t help cnsumers survive, thrive, and ptimize their adjustment in the cmmunity (Mueser, Bnd, Drake, & Resnick, 1998). Page 11 f 50

12 Adult Mental Health Case Management (MHCM) Tennessee What Will Adult Mental Health Case Management (MHCM) Include in Our State? Adult mental health case management (MHCM) is a cmprehensive service that aims t enhance treatment effectiveness and utcmes with the gal f maximizing recvery and resilience ptins and natural supprts fr the adult service recipient. It is cnsumer fcused, cnsumer- centered, and strength- based, with services prvided in an apprpriate, timely, crdinated, effective, and efficient fashin. MHCM fr adults cmprises activities perfrmed by a single mental health case manager r a team t supprt clinical services. The mental health case managers assist in ensuring that the service recipient has access t services. Case management is defined as thse services that are necessary t crdinate an ptimum life style fr the targeted cnsumers. As designed, it will help cnsumers access clinical and ther services that prevent deteriratin in their current mental status and prmte their recvery tward independent living. Case management will als serve t aid the cnsumer in receiving treatment in the least intensive level f care. At least 51 percent f cntacts need t be face- t- face. Like ther kinds f case management, MHCM fr adults requires that the mental health case manager and the service recipient and/r family have a strng, prductive relatinship. This relatinship culd include accepting the individual/family as a respnsible partner in identifying and btaining the necessary services and resurces. MHCM fr adults shuld be delivered in cmmunity settings that are accessible and cmfrtable t the individual and/r his/her family. Further, the service shuld be prvided in a culturally cmpetent manner and be utcme driven. MHCM fr adults shuld be als available 24 hurs a day, 7 days a week. The service itself is nt time limited, as service recipients/families will wrk thrugh case management at their wn pace. Hwever, the intent f MHCM, as prvided fr adults, is t empwer the individual in imprving and maintaining a whlesme quality f life. MHCM can be delivered fr adults thrugh individual r team appraches. In ur state, adult MHCM will be knwn as Adult MHCM- Tennessee. Page 12 f 50

13 Examples f the Primary Duties f an Adult Mental Health Case Manager and Thse Duties That Are Nt Cnsidered the Respnsibility f a Case Manager. Case Managers may assist in a referral t aid the cnsumer in btaining nn- case management services. There are many activities that will be cvered under Adult MHCM- Tennessee. Hwever, there are als a number f services that might be beneficial t cnsumers but may nt be cvered under case management fr the purpses f this manual. Items in the fllwing table prvide examples f the Primary Duties f an Adult Mental Health Case Manager and thse duties that are nt cnsidered the respnsibility f a Case Manager. Case Managers may assist in a referral t aid the cnsumer in btaining nn- case management services. It shuld be nted that the lists are nt designed t be all inclusive. Primary Duties f an Adult Mental Health Case Manager Crdinating and arranging needed services that have been identified in the service plan. Develping, implementing, mnitring and dcumenting a written, individualized, and crdinated case management service plan. The plan shall include dcumentatin f cntacts, the cnsumer s prgress and changing needs in cmpliance with all MCO requirements. Assisting the cnsumer and their supprt system t address issues related t implementatin f the service plan. Develping gals in cllabratin with the cnsumer that fster recvery. Prviding referrals r ther related activities t help the cnsumer btain all medically necessary cvered services and ther supprts t fster recvery. Perfrming activities with the cnsumer that assist in establishing and/r maintaining eligibility fr state and federal assistance prgrams. Services that an Adult Mental Health Case Manager Cannt Directly Prvide but May Initiate a Referral t Obtain Teaching, tutring, training, instructing, r educating the cnsumer, except in s far as the activity is specifically designed t assist the cnsumer r his/her infrmal supprts t independently btain needed services fr the cnsumer. Directly assisting with persnal care r activities f daily living such as bathing, eating, etc. Prviding direct delivery f an underlying clinical, scial, educatinal, r ther service t which the cnsumer has been referred. Transprting the cnsumer when the sle purpse f the service is simply t transprt the cnsumer. Spending time transprting the cnsumer s family members. Prviding services fr r n behalf f ther family members that d nt directly assist the client t access needed services. Page 13 f 50

14 Primary Duties f an Adult Mental Health Case Manager(cntinued) Assisting with scheduling medical/behaviral services and transprtatin as needed. Educating the cnsumer and/r his/her infrmal supprts abut the value f early interventin services and treatment prgrams. Services that an Adult Mental Health Case Manager Cannt Directly Prvide but May Initiate a Referral t Obtain (cntinued) Prviding day care services fr the cnsumer. Perfrming rutine curier services such as shpping. Prviding legal advcacy. Administering medicatins. Prviding utreach activities t ptential clients. Benefit Limitatins n Adult MHCM- Tennessee The Cntractr Risk Agreements (CRAs) include an MCO Behaviral Health Benefits Chart that clarifies type f service alng with any limitatins n benefits. As nted in the chart belw, Adult MHCM- Tennessee will be limited by the fact that medical necessity is a requirement. MCO Behaviral Health Benefits Chart SERVICE Mental Health Case Management (MHCM) Surce: CRA, 2011 BENEFIT LIMIT As medically necessary. What Is the Criteria fr Medical Necessity? The medical necessity standard set frth at TCA Sectin and in assciated rules gvern the delivery f all medical items and services t all enrllees r classes f TennCare beneficiaries. Hence, medical necessity is an essential requirement in the delivery f Adult Mental Health Case Management- (MHCM- ) Tennessee services. Criteria fr medical necessity is cvered in T.C.A , , , , Executive Order N. 23. The rule related t medical necessity is fund in Chapter and presented belw in its entirety. Page 14 f 50

15 Medical Necessity Criteria 1) T be medical necessary, a medical item r service must satisfy each f the fllwing criteria. a) It must be recmmended by a licensed physician wh is treating the enrllee r ther licensed healthcare prvider practicing within the scpe f his/her license wh is treating the enrllee; b) It must be required in rder t diagnse r treat an enrllee s medical cnditin; c) It must be safe and effective; d) It must nt be experimental r investigatinal; AND e) It must be the least cstly alternative curse f diagnsis r treatment that is adequate fr the enrllee s medical cnditin. 2) The cnvenience f an enrllee, his/her family r caregiver, r a prvider, shall nt be justificatin in determining that a medical item r service is medically necessary. 3) Services required fr diagnsis f an enrllee s medical cnditin. a) May include screening services, as apprpriate, prvided that all the ther medical necessity criteria are satisfied. b) Apprpriateness f screening services requires they meet ONE f the fllwing three categries: i) Services required t achieve cmpliance with federal regulatry r statutry mandates under the EPSDT prgram; OR ii) Newbrn testing fr genetic/ metablic defects as set frth in Tennessee Cde Anntated, Sectin ; OR iii) Pap smears, mammgrams, clrectal cancer screenings, prstate cancer screenings, and screening fr sexually transmitted diseases, including HIV, and tuberculsis, in accrdance with natinally accepted clinical guidelines adpted by the Bureau f TennCare. c) Other screening services are apprpriate nly if they satisfy EACH f the fllwing criteria, unless specifically prvided fr herein: i) The Bureau f TennCare, an MCO, r a state agency that perfrms the functins f an MCO determines that the screening services are cst effective; AND ii) Screening via these services must have a significant prbability f detecting the disease; AND iii) The disease fr which the screening is cnducted must have a significant detrimental effect n the health status f the affected persn; AND iv) Tests must be reasnably priced fr purchase; AND v) Evidence- based treatment methds must be available fr treating the disease at the disease stage that the screening is designed t detect; AND vi) Treatment in the asymptmatic phase must yield a therapeutic utcme. d) Services required fr diagnsis f an enrllee s medical cnditin cmprise diagnstic services mandated by EPSDT requirements. Page 15 f 50

16 Medical Necessity Criteria (cntinued) 4) Services required in the treatment f an enrllee s medical cnditin. Treatment may nly cnsist f the fllwing, prvided that all ther elements f medical necessity are satisfied: a) Medical care essential in the treatment f a diagnsed medical cnditin, symptms f a diagnsed medical cnditin, r the effects f a diagnsed medical cnditin and which, if nt prvided, wuld have a demnstrable and significant adverse impact n length r quality f life. b) Medical care essential in the treatment f significant side effects f anther medically necessary treatment (e.g., nausea medicatins fr side effects f chemtherapy). c) Essential medical care, based n an individualized determinatin f a particular patient s medical cnditin, t avid the nset f significant health prblems r cmplicatins that, with reasnable medical prbability, will arise frm that medical cnditin in the absence f such care. d) Hme health services. i) Hme health aide services are necessary in the treatment f an enrllee s medical cnditin nly if such services: (1) Are f a type that the enrllee cannt perfrm fr himself/herself; AND (2) Are f a type fr which there is n caregiver able t prvide the services; AND (3) Cnsist f hands- n care f the enrllee. ii) All ther hme health services are necessary in the treatment f an enrllee s medical cnditin nly if they are rdered by the treating physician, pursuant t a plan f care, and meet the requirements described at subparagraph (a), (b), r (c) immediately abve r (f) immediately belw. Services that d nt meet these requirements, such as cleaning services, general child care services, r the preparatin f meals, are nt required in the treatment f an enrllee s medical cnditin and will nt be prvided. Because children typically have nn- medical care needs that must be met, t the extent that hme- health services r private- duty nursing services are prvided t a persn under 18 years f age, a respnsible adult (smene ther than the health care prvider) must be present at all times in the hme when hme health r private duty nursing services are prvided, unless all f the fllwing criteria are met: (1) The child is nn- ambulatry; AND (2) The child has extremely limited ability r n ability t interact with caregivers; AND (3) The child shall nt reasnably be expected t have needs that fall utside the scpe f medically necessary, TennCare cvered benefits (e.g. the child has n need fr meal preparatin r general supervisin) during the time the private duty nurse r hme health prvider is in the hme withut the presence f anther respnsible adult; AND (4) N ther children shall be present in the hme during the time the private duty nurse r hme health prvider is present in the hme withut the presence f anther respnsible adult. Page 16 f 50

17 Medical Necessity Criteria (cntinued) e) Private Duty Nursing services are separate services frm hme health services. When private duty nurses are authrized by the MCO t prvide hme health aide services pursuant t rule (7)(f) r (8)(f), it is mandatry that the services meet the requirements described at Part 1 immediately abve. f) Hme health services may nt be denied n any f the fllwing grunds: i) Because such services are medically necessary n a lng term basis r are required fr the treatment f a chrnic cnditin; ii) Because such services are deemed t be custdial care; iii) Because the enrllee is nt hmebund; iv) Because private insurance utilizatin guidelines, including but nt limited t thse published by Milliman & Rbertsn r develped in- huse by TennCare MCOs, d nt authrize such health care as referenced abve; v) Because the enrllee des nt meet cverage criteria fr Medicare r sme ther health insurance prgram, ther than TennCare; vi) Because the hme health care that is needed des nt require r invlve a skilled nursing service; vii) Because the care that is required invlves assistance with activities f daily living; viii) Because the hme health service that is needed invlves hme health aide services; OR ix) Because the enrllee meets the criteria fr receiving Medicaid nursing facility services. g) Persnal Care Services. i) Persnal care services are necessary t treat an enrllee s medical cnditin nly if such services are rdered by the treating physician pursuant t a plan f care t address a medical cnditin identified as a result f an EPSDT screening. Persnal care services must be supervised by a registered nurse and delivered by a hme health aide. In additin the services must: (1) Be f a type that the enrllee cannt perfrm fr himself r herself; AND (2) Be f a type fr which there is n caregiver able t prvide the services; AND (3) Cnsist f hands- n care f the enrllee. ii) Services that d nt meet these requirements, such as general child care services, cleaning services r preparatin f meals, are nt required t treat an enrllee s medical cnditin and will nt be prvided. Fr this reasn, t the extent that persnal care services are prvided t a persn under 18 years f age, a respnsible adult (ther than the hme health aide) must be present at all times during prvisin f persnal care services. h) The fllwing preventive services: i) Prenatal and maternity care delivered in accrdance with standards endrsed by the American Cllege f Obstetrics and Gyneclgy; ii) Family planning services; iii) Age- apprpriate childhd immunizatins delivered accrding t guidelines develped by the Advisry Cmmittee n Immunizatin Practices; Page 17 f 50

18 Medical Necessity Criteria (cntinued) iv) Health educatin services fr TennCare- eligible children under age 21 in accrdance with 42 U.S.C. Sectin 1396d; v) Other preventive services that are required t achieve cmpliance with federal statutry r regulatry mandates under the EPSDT prgram; OR vi) Other preventive services that have been endrsed by the Bureau f TennCare r a particular MCO as representing a cst effective apprach t meeting the medically necessary health care needs f an individual enrllee r grup f enrllees. 5) Safe and effective. a) T qualify as being safe and effective, the type, scpe, frequency, intensity, and duratin f a medical item r service must be cnsistent with the symptms r cnfirmed diagnsis and treatment f the particular medical cnditin. The type, scpe, frequency, intensity, and duratin f a medical item r service must nt be in excess f the enrllee s needs. b) The reasnably anticipated medical benefits f the item r service must utweigh the reasnably anticipated medical risks based n: i) The enrllee's cnditin; AND ii) The weight f medical evidence as ranked in the hierarchy f evidence in rule (22) and as applied in rule (6) and (7). 6) Nt experimental r investigatinal. a) A medical item r service is nt experimental r investigatinal if the weight f medical evidence supprts the safety and efficacy f the medical item r service in questin as ranked in the hierarchy f evidence in rule (22) and as applied in rule (6) and (7). This standard is nt satisfied by a prvider s subjective clinical judgment n the safety and effectiveness f a medical item r service r by a reasnable medical r clinical hypthesis based n an extraplatin frm use in diagnsing r treating anther cnditin. Hwever, extraplatin frm ne ppulatin grup t anther (e.g. frm adults t children) may be apprpriate. Fr example, extraplatin may be apprpriate when the item r service has been prven effective, but nt yet tested in the ppulatin grup in questin. b) Subject t the prvisins set frth in subparagraph (c) immediately belw, use f a drug r bilgical prduct that has nt been apprved fr marketing under a new drug applicatin r abbreviated new drug applicatin by the United States Fd and Drug Administratin (FDA) is deemed experimental. c) Use f a drug r bilgical prduct that has been apprved fr marketing by the FDA but is prpsed t be used fr ther than the FDA- apprved purpse (i.e., ff- label use) is experimental and nt medically necessary unless the ff- label use is shwn t be widespread and all ther medical necessity criteria as set frth in rule (1)(a), (b), (c) and (e) are satisfied. d) Items r services prvided r perfrmed fr research purpses are experimental and nt medically necessary. Evidence f such research purpses may include Page 18 f 50

19 Medical Necessity Criteria (cntinued) e) written prtcls in which evaluatin f the safety and efficacy f the service is a stated bjective r when the ability t perfrm the service is cntingent upn apprval frm an Institutinal Review Bard, r a similar bdy. f) Unless a prpsed diagnsis r treatment independently satisfies the criteria fr nt experimental r investigatinal, and satisfies all ther medical necessity criteria, the fact that an experimental/investigatinal treatment is the nly available treatment fr a particular medical cnditin r that the patient has tried ther mre cnventinal therapies withut success des nt qualify the service fr cverage. 7) The least cstly alternative curse f diagnsis r treatment that is adequate fr the medical cnditin f the enrllee. a) Where there are less cstly alternative curses f diagnsis r treatment that are adequate fr the medical cnditin f the enrllee, mre cstly alternative curses f diagnsis r treatment are nt medically necessary, even if the less cstly alternative is a nn- cvered service under TennCare. b) Where there are less cstly alternative settings in which a curse f diagnsis r treatment can be prvided that is adequate fr the medical cnditin f the enrllee, the prvisin f services in a setting mre cstly t TennCare is nt medically necessary. c) If a medical item r service can be safely prvided t a persn in an utpatient setting fr the same r lesser cst than prviding the same item r service in an inpatient setting, the prvisin f such medical item r service in an inpatient setting is nt medically necessary and TennCare shall nt prvide payment fr that inpatient service. d) An alternative curse f diagnsis r treatment may include bservatin, lifestyle, r behaviral changes r, where apprpriate, n treatment at all when such alternative is adequate fr the medical cnditin f the enrllee. e) The fllwing is a nn- exhaustive illustrative set f circumstances that culd fit within the prvisins f rule (7)(d). These examples may r may nt be apprpriate, depending n an individualized medical assessment f a patient s unique circumstances: i) Rest, fluids and ver- the- cunter medicatin fr symptmatic relief might be recmmended fr a viral respiratry infectin, as ppsed t a prescriptin fr an antibitic; ii) Rest, ice packs and/r heat fr acute, uncmplicated, mechanical lw back pain alng with ver- the- cunter pain medicine, as ppsed t x- rays and a prescriptin fr analgesics; iii) Clear liquids and advance diet as tlerated fr uncmplicated, acute gastrenteritis, as ppsed t prescriptin antidiarrheals. 8) The Bureau f TennCare may make limited special exceptins t the medical necessity requirements described at rule (1) fr particular items r services, such as lng term care, r such as may be required fr cmpliance with federal law. Page 19 f 50

20 Medical Necessity Criteria (cntinued) 9) Transprtatin services that meet the requirements described at rule and shall be deemed t be medically necessary if prvided in cnnectin with medically necessary item s r services (T.C.A , , , , Executive Order N. 23.). Wh Will Determine Medical Necessity? The Managed Care Organizatin (MCO) may establish prcedures fr the determinatin f medical necessity. Medical necessity determinatins shall be made n a case by case basis and in accrdance with the definitin f medical necessity defined in TCA and TennCare rules and regulatins. Hwever, this requirement shall nt limit the MCO s ability t use medically apprpriate cst- effective, alternative services in accrdance with Sectin in the Cntract Risk Agreement (CRA). The Bureau f TennCare has ultimate respnsibility in the determinatin f medical necessity. On ccasin, the Bureau may establish r endrse medical necessity guidelines that shall guide determinatins f medical necessity fr specific services r items acrss all MCOs and State agencies perfrming the functin f MCOs. Such guidelines shall be established with input frm all healthcare prviders, be evidence based, and take int accunt all criteria f the statutry definitin f medical necessity. The apprved guidelines will be disseminated t the MCOs and the prvider cmmunity and a cntinuus medical review prcess will be set in mtin t ensure the respnsiveness f the apprved guidelines t advances in medical technlgy and knwledge (CRA, 2011). What Are the Principles Underlying Adult MHCM- Tennessee? The MCO s case management prgram fr adults will be prmted as Adult MHCM- Tennessee. This service will be guided by the fllwing principles: Case managers shall nly deliver case management services. Eligible service recipients shall be assigned t a single case manager, unless they are being served by a team, i.e., a multidisciplinary grup f behaviral health prviders. In the event f the latter, the service recipients shall be managed by a single team. Services shall be rendered in a manner that exemplifies the principle f recvery, acknwledging that peple with mental illness CAN and DO recver (Sherman & Ryan, 1998). Eligible service recipients shall have the right t refuse Adult MHCM- Tennessee services. Page 20 f 50

21 Wh Can Receive Adult MHCM- Tennessee Services? Admissin t Adult MHCM- Tennessee will be based n medical necessity. Services must assist cnsumers in vercming barriers, caused by the mental health cnditin, that are preventing the attainment f gals. The fllwing key cmpnents shuld be addressed in determining eligibility fr Adult MHCM- Tennessee services. The service recipient: Has a diagnsable mental illness that impairs the his/her ability t functin within the cmmunity: Is actively participating in treatment at an utpatient setting r Is reasnably expected t participate in utpatient treatment as a result f referral and/r educatin; Needs assistance utilizing r accessing behaviral health, medical, and/r cmmunity- based services t functin in the cmmunity as necessary fr recvery, including services related t: Emplyment r public assistance. Husing. Childcare. Mney management. Transprtatin. Educatin. Legal matters (Adapted frm U.S. Behaviral Health-CA, 2011). Will All Eligible Service Recipients Receive the Same Level f Adult MHCM- Tennessee Services? Adult MHCM- Tennessee will be prvided as three (3) different levels f case management. One level will be team- based and the remaining tw (2) levels will be delivered thrugh an individual apprach. Tw levels are intensive and ne (1) level is supprtive. MCOs will be expected t ensure delivery f Adult MHCM- Tennessee accrding t the standards set frth by medical necessity guidelines, the CRA, and MCO level- specific guidelines. Peer supprt, i.e., Certified Peer Specialists, might be used as an adjunct t the case manager, where available, in the least restrictive level. At n time, hwever, shuld peer supprt in the frm f Certified Peer Specialists r any ther frm becme a substitute fr case managers in the delivery f case management services. Key cmpnents fr each level f Adult MHCM- Tennessee services are described belw. Page 21 f 50

22 The fllwing charts utlining the service criteria are prvided nly as guidelines t assist MCOs and case manager prviders in determining the apprpriate level f care needed. Level 1 Adult MHCM- Tennessee Team Intensive Services Intrductin Level 1 encmpasses the mst intensive level f Adult MHCM- Tennessee. Services fr this level are designed fr persns f exceptinally high- need and/r high- risk that have a mental illness. Level 1 services als include an interdisciplinary team. Individuals receiving this level f service are likely discnnected psychiatrically and/r medically frm cmmunity based services. They typically shw mre severe psychiatric impairment such as a diagnsis f chrnic, severe psychsis, and may be characterized by a pattern f excessively high service use r needs. Adult MHCM- Tennessee currently recgnizes three (3) team appraches that might be utilized in the delivery f Level 1 services: ACT, CTT, and PACT (CRA, MCO Amendment M- E- W 10 & 7, 2011; CRA, TennCare Select Amendment 27, 2011). Admissin Criteria Admissin t Level 1 Adult MHCM- Tennessee will be based n medical necessity. At a minimum, admissin criteria shuld include the fllwing key cmpnents. The service recipient: Has a diagnsable mental illness that impairs the his/her ability t functin within the cmmunity; Is actively participating in treatment at an utpatient setting r is reasnably expected t participate in utpatient treatment as a result f referral and/r educatin; Needs assistance utilizing r accessing behaviral health, medical, and/r cmmunity- based services t functin in the cmmunity as necessary fr recvery, including services related but nt limited t: Emplyment r public assistance. Husing. Childcare. Mney management. Transprtatin. Educatin. Legal matters (Adapted frm U.S. Behaviral Health- CA, 2011). Page 22 f 50

23 Level 1 Adult MHCM- Tennessee Team Intensive Services (cntinued) Admissin Criteria (cntinued) In additin, persns admitted t Level 1 Adult MHCM- Tennessee wuld need t meet at least TWO (2) f the fllwing cnditins. The service recipient has: Demnstrated extremely pr and/r erratic functining in the cmmunity and culd nt be effectively served thrugh less intensive cmmunity- based services. Been a nnparticipant in traditinal cmmunity- based treatment. Been hspitalized fr at least ne (1) psychiatric admissin. Had at least three (3) emergency psychiatric presentatins either thrugh a crisis stabilizatin unit (CSU) r ther alternative level f care while residing in the cmmunity. Had regular cntact with the legal system. Experienced hmelessness r is at very high risk f lsing cmmunity tenure. Demnstrated cnsistent patterns f high service use r needs. N family, friends, significant thers, r ther identifiable natural supprts t prvide necessary assistance in accessing and/r utilizing services and/r skills that are geared tward recvery. Step- Dwn Criteria Level 1 service recipients transitining t the next level f care might exhibit the fllwing: Alng with his/her team, invlvement in the decisin that the team apprach f case management services is n lnger needed. Participatin in treatment (behaviral health and/r medical). Behaviral health treatment may be pharmaclgical, psychscial, r a cmbinatin f the tw. N hspitalizatins. N invlvement with law enfrcement r the criminal justice system invlving extended incarceratin. Demnstratin f sme ability t identify and/r cmmunicate with family, friends, r significant thers fr infrmal supprt in the management f their illness and/r ther needs and services that will increase the likelihd f cmmunity tenure and mve them tward recvery. Demnstrated prgress in access t r engagement f cmmunity- based services. *The service recipient culd transitin t Level 2a r Level 2b. Page 23 f 50

24 Level 1 Adult MHCM- Tennessee Team Intensive Services (cntinued) Cntinuatin Criteria Cmpnents f cntinued stay fr the service recipient in Level 1 wuld include the fllwing: Still meets admissin criteria. Shrt- term and/r lng- term gals have nt been achieved and the team, including the service recipient, recmmends cntinuatin. Cntinues t need r request significant assistance frm thers t btain any meaningful infrmatin regarding his/her wn mental health status and/r persnal gals and bjectives. A discnnect with cmmunity- based services, including psychiatric and medical, cntinues t exist. Has experienced relapses in the cmmunity. Discharge Criteria Discharge fr Level 1 service recipients wuld cnsider the fllwing cmpnents: At least 70% f the shrt- term gals necessary fr transitin t a lwer level f care (Level 2a r 2b) were met. Alng with his/her team, there was mutual agreement t terminate this level f Adult MHCM- Tennessee service. Demnstratin f little t n prgress in meeting targeted gals fr sme extended perid f time, despite dcumented attempts t engage him/her in services. Refusal t participate in crdinatin f services thrugh the medical hme fr sme extended time perid. Mvement ut f the service area. Lss f cmmunity tenure thrugh lng- term incarceratin r the need fr skilled- nursing care, fr example. Death. Maximum Caselad Size Adult CTT 20 individuals:1 team 20 individuals:1 case manager ACT/PACT 100 individuals:1 team 15 individuals:1 case manager Minimum Face- t- Face Cntacts Adult CTT, ACT, r PACT One (1) cntact per week Page 24 f 50