Medicaid Application for Intensive Outpatient Programs Application Checklist for Providers

Transcription

1 Provider information Agency Name: Physical Address: If applying for multiple sites or applying to serve adolescents and/or adults please note and list specific physical locations: Mailing Address (if different than above) for each site: Website: Provider Contact Information for Responsible Party Completing Application: Name/Title: Address: Office Phone: Mailing Address: Mobile Phone: IOP Services are Provided to: ( Eligible Recipients) Adults, age 18 and over: IOP services are provided to adults aged 18 years and over diagnosed with substance abuse disorders or with co-occurring disorders (serious mental illness and substance abuse) or that meet the American Society of Addiction Medicine (ASAM) patient placement criteria for level two (II) - intensive outpatient treatment. Youth in Transition, ages years 1 P age

2 Youth, years: IOP services are provided to youth, aged years, diagnosed with substance abuse disorders or with co-occurring disorders (serious emotional disturbance and substance abuse) or that meet the American Society Of Addiction Medicine (ASAM) patient placement criteria for level two (II) - intensive outpatient treatment. This Agency is a: Community Mental Health Center (CMHC) Rural Health Clinic (RHC) Federally Qualified Health Center (FQHC) Indian Health Services (IHS) Facility PL Tribal Facility An agency requesting approval from MAD submitting the documentation necessary to demonstrate that the agency meets all requirements of an intensive outpatient program services and supervision requirements 2 P age

3 All items listed in bold-faced, underlined text in the Assessment Criteria column are pass/fail. The Provider must demonstrate that these items have been adequately supported in the documents submitted in their application. If any one of these items fails, then the application as a whole fails. It is MAD s intent that upon approval of this application, the Provider will implement their MAD IOP program in accordance with the approved policies and procedures as submitted. The use of the clinical practice standards, evidence-based practices, and the most current Service Definition provide guidance to the Provider of the information necessary to be approved as a MAD IOP provider. The Provider must comply with all sections of MAD NMAC, Intensive Outpatient Services rule. If the Provider is proposing multiple sites, the responses, documents, policies/procedures must specifically address how the agency will coordinate and collaborate between the sites. In particular, how staffing, supervision, and training will be managed. Each site will be individually provisionally and fully enrolled. If the Provider is proposing to serve both adolescents and adults, the application must specifically detail the uniqueness of each population in its policies/procedures, documents and responses. A. Agency Policies and Procedures/Standard Operating Procedures (SOP)/IOP Guidelines Item Assessment Criteria Yes Comments All Items Underlined and in Bold Font Are Pass/Fail Regulation: The IOP services are provided through an integrated multi-disciplinary approach or through coordinated, concurrent services with behavioral health providers, with the intent that the IOP shall not exclude consumers with co-occurring disorders. In order to meet this requirement a provider must have in place either an IOP Service Team (AKA Treatment Team) when the approach is through coordinated concurrent services; or, a Multidisciplinary Team (MDT) when the approach is through an integrated multi-disciplinary approach. Description: 1. IOP service team (AKA treatment team): The IOP Service Team is comprised of the agency behavioral health providers and is led by the IOP supervisor. IOP team members are expected to maintain documented communication linkages with the consumer s primary mental health providers and other critical service linkages as identified in the assessment and treatment plan (e.g. HIV health care; criminal justice and so forth). Teams are in place to serve individuals or families that have service needs identified in multiple domains, such as co-occurring substance and mental health disorders, and specifically assure that services are coordinated and consistent across domains. The clinical supervisor maintains responsibility that staffing for all individuals meets requirements and addresses the needs identified by assessment and service planning on a case-by-case basis during regularly scheduled staffing meetings. 2. Multi-disciplinary team (MDT): As possible and appropriate to the individuals needs and community capacity, the team will consist of the consumer and family/guardian, natural supports, CCSS workers, psychiatrist, nurses, counselors and clinicians, case managers, CYFD staff, other ancillary providers (vocational, residential, housing, criminal justice, hospital liaison), school, law enforcement, and courts, who all work collaboratively on the team and meet face-to-face led by the clinical IOP supervisor. The MDT develops the initial treatment plan and then monitors the consumers progress in meeting established goals and outcomes. Based on the documented period reviews by the MDT, changes in approaches, goals, outcomes and linkages with other services across domains should occur. 3 P age

4 A. Agency Policies and Procedures/Standard Operating Procedures (SOP)/IOP Guidelines Item Assessment Criteria All Items Underlined and in Bold Font Are Pass/Fail Yes Comments A1. The IOP services are provided through an integrated multi-disciplinary approach or through coordinated, concurrent services with behavioral health providers, with the intent that the IOP service shall not exclude consumers with co-occurring disorders. ( ) 1. Provide Policies and Procedures that specifically support an integrated multidisciplinary team or IOP service team. 2. Policies and Procedures specify the frequency and regular scheduling of team meetings. Description: provision of services: The intent of IOP services is to enable providers to make available high quality, comprehensive, evidence-based behavioral healthcare that maximizes integration of mental health and substance services related to medical necessity determined during assessment and evaluation. Due to the structure of current evidence-based program as primarily substance disorder related curricula, many mental health issues may need to be addressed during individual counseling or psychoeducational groups. A2. Provision of substance, mental health, or COD services ( D) 1. Provide Policies and Procedures that support the provision and integration of mental health and substance abuse services, inclusive of co-occurring disorders, high-risk situations and crisis planning and intervention. Description: Time-limited and multi-faceted services: Each current evidence-based program specifies the dosage and duration of services. For persons with severe mental illness, dosage may be reduced and duration increased as appropriate as determined in the service plan. Services are provided through IOP groups, individual counseling, and psycho-education groups. Description: The duration of IOP intervention is typically from three to six months; the amount of weekly services is directly related to the goals and objectives specified in the eligible recipient s treatment or service plan. ( E) Ongoing eligibility will be effectively established through 90 day updates to the service plan document if the IOP course of treatment is longer than 90 days duration. The evidence-based curriculum specifies intensity and duration of the normal course of treatment. In addition, persons experiencing severe mental illness with substance related disorders may need adjustments to the mix between intensity and duration, such that intensity may be reduced with duration of treatment service increased. This must be addressed on a case-by-case basis with sufficient and definitive documentation supporting medical necessity and appropriateness of IOP treatment. IDDT best practice course of treatment: The approved IDDT model incorporates a course of treatment IOP curriculum that specifies intensity and duration of treatment, and 4 P age

5 A. Agency Policies and Procedures/Standard Operating Procedures (SOP)/IOP Guidelines Item Assessment Criteria All Items Underlined and in Bold Font Are Pass/Fail Yes demonstrates medical necessity at 90 day intervals through updates to the individual s service plan document. A3. IOP services provide a time-limited, multi-faceted 1. Provide Policies and approach to treatment service for eligible recipients who Procedures/SOP/IOP guidelines that require structure and support to achieve and sustain specify time-limit (duration) of IOP recovery. ( ) ( E) services (as recommended by the EBP utilized). 2. Specify the IOP guidelines that the intensity of weekly services will be directly related to the goals and objectives specified in the treatment/service plan and are aligned with the IOP EBP curriculum. 3. IOP guidelines specify service plan updates at 90 days. 4. Policies and Procedures specify that IOP 4. services are integrated with other services at provider agency. Comments A4. Research-based model specific to IOP services ( F) IOP services must be rendered through a researchbased model: (1) Matrix Model Adult Treatment Model (2) Matrix Model Adolescent Treatment Model (3) Minnesota Treatment Model (4) Integrated Dual Disorder Treatment (5) Any models other than those identified above must be approved by HSD or its authorized agents. G. Services not provided in accordance with the conditions for coverage as specified in and NMAC, Intensive Outpatient Program Services, are not considered covered services and are subject to recoupment. 1a. The provider uses one of the EBP models specified in the regulations. 1b. If not, specify (in comments section) what curriculum is used and if it is approved. 2. Provide Policies and Procedures that specify formal training in the provider s EBP IOP curriculum for IOP supervisor. 3. Policies and Procedures specify training in the provider s EBP IOP curriculum for IOP clinicians. (Note: training does not have to be formal and can be conducted by clinical supervisor.) 1a. 1b. 5 P age

6 A. Agency Policies and Procedures/Standard Operating Procedures (SOP)/IOP Guidelines Item Assessment Criteria All Items Underlined and in Bold Font Are Pass/Fail Yes Comments Description: Co-occurring disorders: The term co-occurring disorders (COD) refers to co-occurring substance-related and mental/emotional disorders. Persons said to have COD have one or more substance related disorders as well as one or more mental disorders. At least one disorder of each type can be established independent of the other and is not simply a cluster of symptoms resulting from a single disorder. When assessment is carefully conducted, the symptoms of each diagnosis that contribute to the functional impairment(s) will be clearly ascertained, communicated, and addressed. What this means in practical terms is that a simple diagnosis of SMI, SED/At Risk or substance use patterns will not suffice to present a clear picture of how an individual experiencing COD will manifest symptoms; that the presentation of impairment may be powerfully increased or decreased based upon the persons constitution and susceptibility and the specific interactions between substance use and the mental illness. It is likely that the symptoms of one disorder will have effect on the other disorder. (the New Mexico COD Competent Intensive Outpatient Program Manual) A5. Treatment services should address co-occurring mental health disorders, as well as substance use disorders, when indicated. ( ) 1. Provide Policies and Procedures that specify an assessment protocol for COD consumers. 2. Policies and Procedures specify that an integrated summary describing the interactions or the interrelated effects of the disorder dynamic for the co-occurring diagnoses is included in the assessment. Description: Cultural sensitivity and recovery/resiliency: A workable definition of culture is: a shared system of symbols, beliefs, attitudes, values, expectations, and norms of behavior. Recovery-oriented care is what clinical mental health, addiction treatment, and integrated service practitioners offer in support of the individual/family s own recovery efforts. The recovery process refers to how persons with or impacted by a mental and/or substance disorder actively manage the disorders and reclaim their lives in the community. A6. Services must be culturally sensitive and incorporate recovery and resiliency values into all service interventions. ( ) 1. Provide Policies and Procedures that support recovery and resiliency values, or as evidenced in a Bill of Client Rights, Vision, Values, or other statements of organizational intent. 2. Provide Policies and Procedures that support culturally sensitive values, or as evidenced in Vision, Mission, or other statements of organizational intent. Description: Medication management services: Pharmacotherapy and medication management includes the use of appropriate medications to manage substance, mental health or co-occurring disorders and use of a recovery-based approach including shared decision making, informed consent, and an active role on multi-disciplinary teams. 6 P age

7 A. Agency Policies and Procedures/Standard Operating Procedures (SOP)/IOP Guidelines Item Assessment Criteria All Items Underlined and in Bold Font Are Pass/Fail A7. Medication management services are available to 1. Provide Policies and Procedures that oversee use of psychotropic medications. ( specify that medication management D) services specific to substance-related, mental and emotional, or co-occurring disorders COD are available for IOP service recipients (either in-house or by referral), and that there how the provider will document linkage to the service team personnel. Yes Comments A8. Documents that must be provided by agency if applying for enrollment as an IOP agency requesting approval from MAD. 1) Organizational Chart 2) Clinical IOP Employee Training Plan that specifically includes IOP model training including protocols when dealing with disruptive or potential suicidal client behavior) 3) Protocol for referring recipients to a 24-hour Crisis Line 4) If the agency is conducting drug screenings, Urinalysis Collection Protocol and accompanying form utilized 5) If agency does medicine administration, Medication Administration Protocol and accompanying form utilized P age

8 B. Quality Management Documentation Item Assessment Criteria Yes Comments Description: Evaluation: quality management processes ensure that the review, evaluation, editing, changes or adaptations of all policies and procedures, SOP s, etc, occur on an annual or as needed basis to ensure that they are current with all other applicable change and modifications to the organization business stance, funding changes, service implementation changes, staff changes, etc. Professional and clinical supervision processes are reviewed and evaluated to ensure that all required supervisory practices are adequately accomplished and implemented. QA monitors, evaluates and assesses outcome measures identified by the consumer, the provider or by the purchaser of services. Quality management reviews record keeping and data management, HIPAA, 42 CFR Part 2, etc, the QA officer and committee review records and record keeping processes to assess that satisfactory records and documentation are maintained and protected adequately. B. IOP providers are required to develop and implement a program evaluation system. ( F) B1. Documents that must be provided by agency if applying for enrollment as an IOP agency requesting approval from MAD. 1. Provide the IOP-specific program evaluation (quality management) to be utilized. 2. Describe how the IOP program will track fidelity to the model. 3. Describe quality management meetings that are regularly scheduled. 4. Describe how the IOP-specific program evaluation system will be used to track and/or evaluate client outcomes. (Client Outcomes may include customer satisfaction surveys, retention into service rates, drop-out rates, re-admittance/relapse and lapse rates, incarceration or hospitalization data, or readily identifiable information and data specific to the IOP that may be contained in the quality management reports.) 1. Description of how program success will be measured, such as: Demographics of recipients serve; any effect on the utilization of criminal justice system by enrolled recipients; changes in recipient employment; numbers and reasons why recipients did not complete IOP program. 2. IOP policies and forms to gather and how this information will be internally analyzed concerning recipient program satisfaction and their beliefs of the effectiveness of their services P age

9 3. IOP policies and forms that will summarize program successes and areas of improvement and how this information will be implemented by agency. C. Agendas, schedules, logs and related systems documentation Item Assessment Criteria Yes Comments Description: Agendas, schedules, logs, and rosters: Provide forms that will be used for meetings, training, service provision, case reviews, and supervisory scheduling. Documents that must be provided by agency if applying for enrollment as an IOP agency requesting approval 1a. from MAD. 1. Specific to the agency IOP program Supervision forms: a. that reflect follow-up from previous meetings b. that document planned training and follow-up those trainings were attended and improvements made in performance c. schedule of individual supervision dates and time 2. Ongoing employee training plan that specifically includes relevant opportunities for staff to learn more about IOP model fidelity and compliance 3. Training plan for staff on how to handle potentially disruptive or unruly client behavior 1b. 1c. 9 P age

10 D. Supervision Item Assessment Criteria Yes D1. Each IOP program must have a clinical supervisor. The clinical supervisor may also serve as the IOP program supervisor. Both clinical services and supervision by licensed practitioners must be conducted in accordance with respective licensing board regulations. An IOP clinical supervisor must meet all the requirements listed in column 2. ( E) 1. Provide a job description for the IOP clinical supervisor. 2. Specifically the job description details that the supervisor: a. Has an active licensure as an independent practitioner b. Has two years relevant experience with IOP eligible recipients. c. Has one year documented supervisory experience. d. Has education, formal, or staff development in both mental health and substance abuse treatment. e. Has formal training and/or certification for EBP IOP curriculum. 3. Provide the supervisory policies that specify how supervision is to be provided in high-risk or crisis situations. 4. Provide the policies that specify supervision for the provision of mental, substance or co-occurring services. 2a. 2b. 2c. 2d. 2e. 4. Comments 10 P age

11 E. Personnel Files Item Audit Activity- On Site Yes E1. Services must be culturally-sensitive and incorporate recovery and resiliency values into all service interventions. ( ) 1. Provide the forms that demonstrate that recovery and resiliency values are embedded in the job descriptions and administrative and supervisory guidelines. 2. Provide training plans that cover recovery and resiliency values for IOP staff. 3. Provide training plans that cover cultural competency for IOP staff. 4. Provide documentation that the agency has a plan to match linguistic facility to the needs of the community served when appropriate. 5. Provide documentation that the program will attempt to have staff employed who are representative of the community served. 6. Provide the plan on how translation services to be made available to persons with limited English proficiency. 7. Provide a plan on how services will be made available to persons who are communication impaired (blind, deaf, etc) Comments E2. ELIGIBLE PROVIDERS: Services must be provided within the scope of the practice and licensure for each provider and must be in compliance with the statutes, rules and regulations of the applicable practice act and must be eligible for reimbursement as described in B-E NMAC Behavioral Health Professional Services. ( E) 1. Provide policies to ensure that IOP clinicians have active New Mexico licensure that match the scope of services they are providing. 2. Provide the program s plan for the education, formal training, or the staff development specific to co-occurring disorders for IOP clinicians. (Note: training can include staff development and/or training from clinical supervisor) 3. Provide the policy that will enforce that IOP clinicians are trained in EBP IOP curriculum in compliance with State of NM MAD Rule. (training may be conducted in-house by supervisory staff 11 P age

12 E. Personnel Files who have attended formal EBP training) 4. Describe how staff will receive COD, EBP, and other appropriate training as indicated by their supervisor in either policy or procedure. 4. E3, Documents that must be provided by agency if applying for enrollment as an IOP agency requesting approval from MAD. 1.Employee Performance Evaluation for IOP program 12 P age

13 F. Client File Item Assessment Criteria Yes F1a ELIGIBLE RECIPIENTS: A. IOP services are provided to youth, aged years, diagnosed with substance abuse disorders or with co-occurring disorders (serious emotional disturbance and substance abuse) or that meet the American society of addiction medicine (ASAM) patient placement criteria for level two (II). F1b. IOP services are provided to adults aged 18 years and over diagnosed with substance abuse disorders or with cooccurring disorders (serious mental illness and substance abuse) or that meet the ASAM patient placement criteria for level two (II) - intensive outpatient treatment. (See next row for a list of ASAM criteria) F2. ASAM: Levels of Care: ( A) Level 0.5: Early Intervention Services - Individuals with problems or risk factors related to substance use, but for whom an immediate substance -related disorder cannot be confirmed Opioid Maintenance Therapy (OMT) - Criteria for Level I Outpatient OMT, but OMT in all levels Level I Outpatient Treatment Level II.1 Intensive Outpatient Treatment Level II.5 Partial Hospitalization Level III.1 Clinically-Managed, Low Intensity Residential Treatment Level III.3 Clinically-Managed, Medium Intensity Residential Treatment (Adult Level only) Level IV Medically-Managed Intensive Inpatient 1. Provide the eligibility policies that determine that an individual meets the eligibility criterion of ASAM level II.1 services: IOP services or diagnosed with substance abuse disorders or with cooccurring disorders as specified by the diagnostician documented in Assessment (H0031-U8) or a Diagnostic/Evaluation (90801) or other diagnostic evaluation as approved by the Medical Assistance Division that is current, (within 12 months) completed, signed and dated by a licensed clinician under the supervision of a licensed Independent Clinician. 2. Provide the level of care specified in the individualized service plan that specifies the level of care and will address the domains of service identified in the Assessment/Diagnostic evaluation appropriate to IOP services. Comments 13 P age

14 F. Client File Treatment F3. Before engaging in an IOP program, the eligible recipient must have a treatment file that contains a diagnostic evaluation and an individualized service plan that includes IOP as an intervention. ( C) Individual case files contain evidence of culturallysensitive and recovery and resiliency-based treatment. 1. Provide the Individual Service Plan that will address all issues identified in the Assessment/Diagnostic evaluation appropriate to IOP services. 2. Form does assess co-occurring disorders addressed. 3. There is a relapse and/or crisis plan (may be the same document). 14 P age

15 F. Client File ( ) 4. There is place for progress note for each treatment session including: IOP services, and/or individual counseling, and/or psycho-ed. 5. There is a place for records and notes pertaining to how all other domains of service identified in the assessment/evaluation have been addressed in the service plan. 6. There is a place for the consumer and/or parent/guardian, as appropriate, to identify and agree to specific, personal goals of treatment, and signed documents appropriately. 7. Provide a copy of the Release of Information forms specific to treatment needs (may include individuals or other agencies providing services). 8. Provide a copy of the Client Bill of Rights that will be signed and located in the client s chart. 9. Provide a copy of the note to be utilized related to input from the IOP service team or MDT. 10. Provide a copy of the treatment schedule/attendance document. It should have the ability to track and match the recommended EBP service intensity specific to client needs and capability as documented in the Assessment (H0031- U8) or a Diagnostic/Evaluation (90801) or other diagnostic evaluation as approved by the Medical Assistance Division. 11. Provide the policy or procedure that directs that a Diagnostic Evaluation (90801) Assessment (H0031-U8) or other diagnostic evaluation as approved by the Medical Assistance P age

16 F. Client File Division is to be current, (within 12 months) stating it must be completed, signed and dated by a licensed clinician under the supervision of a licensed Independent Clinician. 12. If applicable and appropriate, provide a copy of the policy or procedure detailing medication management services provided to the client either in-house or by referral, and are all medication services and how the referrals will be adequately documented. 1 F4, Documents that must be provided by agency if applying for enrollment as an IOP agency requesting approval from MAD. 1. Client rights and grievance procedures that include the Single Entity s and Fee-for- Service (FFS) rights for fair hearings. 2. Discharge Planning form should have sections for: a. Services, initially and updates, that reflect growth and needs of the consumer so the treatment plan and discharge plan are consistent and cohesive b. Family and community supports c. The development level, any unique reconsideration for that consumer to continue in recovery. d. Steps after discharge that support the consumer in recovery a. b. c. d. 16 P age

17 Certification individual(s) completing application: Provider Representative Provider Representative Print name Date Signature Print name Date Signature 17 P age