Discharge Planning and Community Based Services. Vicki Beth Blattert, QI Reviewer Dr. Becky Braymen, Clinical Director

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1 Discharge Planning and Community Based Services Vicki Beth Blattert, QI Reviewer Dr. Becky Braymen, Clinical Director

2 Objectives Communicate required Magellan and Medicaid standards and discharge planning criteria, Review A guidelines Transition and Discharge Planning, Offer in-depth review of the 5 criteria of discharge planning applicable to all 24-hour care facilities, Familiarize participants with features of MST, IOP, CTA, DT and individualized intensive outpatient, and how to authorize, Discuss the role of Intensive Care Management (ICM) for youth discharging out of 24-hour facilities back to their home communities, Share web access resources for regional community based services. Magellan Health Services, Inc. 2

3 Definition Nebraska Medicaid defines Discharge Planning as: A process used to decide what a patient needs for a smooth move from one level of care to another. A process ongoing, not fixed element; stays a process until discharge

4 Definitions, continued Discharge Summary Accreditation requirement Discharge Transfer Within a program Discharge Instructions Walking Document

5 Discharge Planning is Important because Helps all parties have a clear understanding and expectation of the plan of action at discharge. Helps providers keep in mind the ultimate aim of providing supportive services to the client. Studies have shown that ambulatory follow-up rates are improved when a discharge plan is present even for clients with a past history of non-compliance.

6 Discharge Planning is Important because Decreases chances of readmission to higher level of care Maintains treatment gains Better follow-up compliance Promotes recovery Focus is on the future when planning begins at admission Provides safety

7 Discharge Planning Provides for Physical Safety Written Written information can be helpful. Discharge can be an emotionally charged time for parents. Immediate Immediate hands on information for line staff, no need to wait for chart s physical transition or opening of new chart. Awareness Provides caregiver awareness of issues to watch for during first hours of adjustment: selfharm, run risk, suicide, danger to others. Safety Safety plan: sex offender risk, potential triggers, successful calming techniques. Needs Next caregiver can immediately meet specific needs of each client at new placement: Special dietary needs Physical limitations Medical conditions/allergies Educational requirements Information on current treating Physician, Dentist, etc.

8 Discharge Planning Provides for Medication Safety Timing of last dose of medication Continuation of medication Arrangement for continuing supply or scripts Reconciliation of medication Pre-admission medications compared with post-discharge to see that there are no duplications, omissions, harmful side-effects, etc.

9 Basics of the Discharge Process Include: Evaluation Discussion By qualified personnel at beginning of admission process Requires participation of treatment team and active involvement of the member s family and/or social supports. Planning Placement: return to home or to another care facility Determining If Caregiver training or other support is needed Referrals Appropriate support organizations in the community Arranging follow-up appointments Insures better post-discharge care, follow-up, provides an action plan to continue services, treatment and care without interruption.

10 During Treatment: Discharge Planning should include: Anticipated discharge date Next level of care and rationale for referral Permanency plan Updates as treatment progresses Evidence of team approach Client, Family/Guardian, Case Worker, Facility Treatment Team and Supervising Practitioner

11 At Time of Discharge: Discharge Planning Should Include: First appointment within 7 day of discharge Time, date, Provider phone number Supply of medication or prescription Time and date of last dose; time for next dose Names, dosages, and frequencies for each medication Linkages with peer services and other community services: Schools Primary Care Provider, other Health Professionals A Plan to communicate clinical information to the Provider of post-discharge care (Pre-treatment Assessment, most recent CANS information sent previously) Written instructions on how to contact your facility in the event of a crisis Especially important when a client discharges home Evidence of client participation

12 Discharge Planning Criteria NAC 471 Chapters 20 & 32 Criteria One: Discharge instruction documented on the day of discharge and shared with the next caregiver. Criteria Two: Next treatment appointment scheduled prior to the Medicaid member s discharge; information shared with the next caregiver. Criteria Three: Current medications identified and necessary instructions given to the next care giver. Criteria Four: Emergency contact numbers identified for the next caregiver. Criteria Five: Member restrictions on daily activities documented, if necessary.

13 Contents of Discharge Information Sheet Discharge Placement Name, address and Phone Number Discharging Provider Emergency Number Physical/Medical Conditions Special dietary needs, physical limitations, allergies, wound care, physician information, on-going care required ( i.e. braces) Medication Time of last dose, dosage schedule, possible side effects, supply of Medication sent with client, refill prescriptions Safety or Crisis Management Necessary Precautions: self-harm or other harm, aggression, sex offender issues Potential triggers; intervention strategies, emergency or support contacts/phone numbers Restrictions on physical movement Follow-Up Care Provider name, phone number, address and date of next appointment Suggestions for community resources Educational needs: previous school contacts, special education, Interpreter, etc. Suggested approach: strengths/abilities, successful calming techniques Signatures and Date Discharging Provider Parent/Guardian Client

14 Sample Discharge Plans

15 Sample Discharge Plans

16 Sample Discharge Plans

17 Discharge Instruction Signature Sheet

18 Questions? Consider what is most helpful to you, as a Provider, when you have an intake provide that information for the next care giver in the Discharge Instruction Sheet.

19 Community Based Options For Youth Transitioning From 24 Hour Treatment Facilities.

20 To transition a youth from residential treatment to community-based services: The Residential Provider should have the first follow-up appointment set within 7 days of discharge and provide the Provider name and contact information to the client s guardian. The Residential Provider should forward (with a proper release of information) to the Community-Based therapist: 1. All current medications; time of the most recent dosage, possible side effects 2. Medications being sent with the member 3. An emergency contact person should confusion or question arise during transition 4. Discharge plan that documents safety precautions or restrictions to maintain safety. 5. Pre-treatment Assessment 6. Discharge CANS The Community-Based therapist will complete an initial diagnostic interview and update the treatment plan.

21 Medicaid Community-Based Treatment Services Assessment Services Outpatient Medication Management, Individual, Crisis Sessions, Family, and Group Therapy) Community Treatment Aide (CTA) Intensive Outpatient (IOP) includes MST Day Treatment (DT) Partial Hospitalization (PHP)

22 Outpatient Services Medication Management Individual, Family, and Group Therapy authorized by a therapist in the youth s home community by calling Magellan to determine eligibility and availability of authorizations. Crisis Sessions can be authorized for a youth in need of immediate intervention by contacting a Care Manager at Magellan.

23 Community Treatment Aide (CTA) By definition in the Nebraska Medicaid Managed Care Plan (NMMCP) Clinical Guidelines, (Provider Handbook Supplement, Appendix C) CTA services: Are Supportive, directive, and teaching services provided in the home, school, and other appropriate location that assist the member or the member s family to improve their capacity for living in the least restrictive environment. Magellan Health Services, Inc. 23

24 CTA Application Process - All Initial Requests For all initial CTA requests: Requests must be made by a treating clinician. Requests must be part of the overall treatment plan, goal directed and time limited. Requests must be in writing except when a child is in inpatient care. Magellan Health Services, Inc. 24

25 CTA Applications Child in Inpatient Care In addition to the standard application criteria, if a youth is in inpatient care, And CTA is requested as part of the discharge plan, the care manager can provide an initial authorization of 12 hours over a two-week period. Before any additional CTA services can be authorized, the standard application packet must be submitted. The Care Manager will review the CTA request to make sure it is therapeutically appropriate and that the request is part of the overall treatment plan. Magellan Health Services, Inc. 25

26 Intensive Outpatient (IOP) Intensive outpatient is a level of care between day treatment and traditional outpatient. Services may be delivered in a group format within a facility or as an individualized format within a member s own home. This level of care is intended to prevent admissions to higher levels of care or to serve as aftercare for members who are transitioning from higher levels. Intensive Outpatient services are available to members aged 20 and younger.

27 MST Multisystemic Therapy (MST) Youth ages with serious juvenile justice and at risk for being removed from their own homes Pragmatic and goal-oriented model gives families skills and resources to improve family disciplinary practices, enhance family relations, decrease deviant peer interactions, increase youth association with pro-social peers, and develop connection to the community Reduced days in out-of-home placement by 47-64% Reduced long-term arrest rates by 25-70% An evidence-based program (SAMHSA) MST is available in Lincoln, Grand Island and Kearney Magellan Health Services, Inc. 27

28 Individualized Intensive Treatment Services Package Intensive therapy components tailored to each youth s specific needs Requires an exception by the Medical Director. Examples: 24 hour crisis response clinicians, individual, family and group therapies, medication management, community treatment aides, day treatment, etc. Magellan Health Services, Inc. 28

29 Day Treatment A comprehensive, community-based service. Uses a multidisciplinary approach which includes more intensive and comprehensive services than can be provided at the outpatient level. Ranges from 3 to 6 hours per day Includes individual (once per week minimum), group (once per day minimum) and family (once per week minimum) therapies

30 Partial Hospitalization Can be used as a transitional level of care from inpatient or residential treatment. Level of intensity similar to an inpatient program setting. Structured therapeutic milieu with 3 hours (half day) to 6 hours (full day) Includes individual therapy (2-3 times per week); group (daily); family therapy (minimum of 2X per week), and psychoeducational groups The partial hospitalization program may used locked seclusion when utilized in a manner consistent with the Agency s national accrediting body standards.

31 Intensive Care Management (ICM) Program Description One care manager is assigned to each eligible individual as a contact for all information from Magellan in terms of authorizations, referrals, etc. Able to develop creative solutions to meet individuals unique needs Vast knowledge of providers across the State of Nebraska Empowering individuals and their families to obtain the goals they set Participate in team meetings and decision making Provides closer oversight of treatment

32 ICM Criteria for Members Discharging from Residential Treatment Non-state ward youth who have been in a residential level of care (priority will be given to RTC and ETGH) and will be discharging back into a community in Nebraska. 18 year old youth who will need coordination for adult mental health services (TAY); at minimum youth would have to meet minimum diagnostic criteria for SPMI diagnoses. Non-State Ward youth who has discharged from a residential treatment facility and holds no open authorization at 45 days post-discharge. State Ward youth who has discharged from a residential treatment facility and holds no open authorization at 45 days postdischarge.

33 COMMUNITY RESOURCES Medicaid therapy reimbursements are based on medical necessity, not as support or maintenance service or a court order. Once a client has reached a baseline status, community resources are the appropriate level of service. Mental / Behavioral Health Provides information to help link consumers to support groups and personal advocacy resources in the community. The site also provides a repository of evidence-based practices successful, creative ways for communities to respond to their behavioral-health needs

34 Resources for Difficult Economic Times (United Way) Quick Search links are an easy way to search for information on food and shelter, general assistance, utility assistance, and employment and job training services. Search for providers and referrals Statewide data base with numbers, web sites, and contacts to connect with services Information for families with special needs Information for consumers and families on community resources, separated by Region.

35 Community Based Service Providers The next few slides contain listings of Community Based Service Providers across the state of Nebraska. Please keep in mind that this list may change depending on which programs Providers continue to offer and which programs may be at capacity. If you are interested in referring a client to one of the services listed, please contact the office or facility to discuss availability and referral.

36 Partial Hospitalization Providers

37 Day Treatment Providers

38 Community Treatment Aid Providers

39 Intensive Outpatient (IOP)

40 Nebraska Magellan Key Staff: Rebecca Braymen, Ph.D., LP, Clinical Director, Oversees all clinical functions of the Nebraska CMC Vicki Beth Blattert, LIMHP, Clinical Reviewer, Carl Chrisman, MA, LMHP Clinical Supervisor, Primarily responsible for adult and transitional MH/SA treatment Lisa Christensen, Ph.D. LIMHP, LADC and CMFT Director of Quality and Compliance, Oversees assurance of quality improvement functions Jeff Coffman, M.D., Medical Director, Provides medical oversight for Nebraska CMC Teresa Danforth, BA Network/Area Contract Manager, Primary contact for credentialing and contracting of facilities and organizations Tamara Gavin, LMHP/LCSW Clinical Supervisor, Primarily responsible for youth MH/SA treatment Kathryn Kvederis, M.D., Medical Director, Medical oversight for Nebraska CMC Sue Mimick, MBA, General Manager, Responsible overall for functions of Nebraska CMC Lori Hack, JD, Family and Consumer Advocate, Assists Consumers and Families to find and access resources. Don Reding, MA, Operations Manager, Responsible for IT/Reporting Operations of the Nebraska CMC Charles Wadle, D.O., ASAM - Consultant - Provides consultation related to substance abuse issues as needed Magellan Health Services, Inc. 40

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