TennCare Level 2 Adult Mental Health Case Management Definition

Transcription

1 TennCare Level 2 Adult Mental Health Case Management Definitin Level 2 adult case management is defined as services furnished t assist individuals in gaining access t needed medical, scial, educatinal, and ther services, eligible under the State Plan wh reside in a cmmunity setting r are transferring t a cmmunity setting, in accrdance with Cde f Federal Regulatins (CFR) Case management des nt include, and FFP is nt available in expenditures fr, services defined in CFR f this chapter when the case management activities cnstitute the direct delivery f underlying medical, educatinal, scial, r ther services t which an eligible individual has been referred. Level 2 adult mental health case management is fr individuals wh have a diagnsed mental illness and demnstrate skill and/r resurce deficits which impair their ability t achieve persnal gals independently. Level 2 adult mental health case management crdinates a range f recvery riented services prvided t assist and supprt individuals in develping their daily living skills, achieving wellness and ptimum functining. Level 2 adult mental health case management is persn-centered, strengths based, and fcused n recvery and resiliency. The frequency and intensity f Level 2 adult case management is prvided t individuals based n their needs and medical necessity. Level 2 adult mental health case management prvides crdinatin f services including assessment, advcacy, linkage, referral, mnitring, supprt, and training t assist adults with serius and persistent mental illness access t needed medical, behaviral health, scial, educatinal, and ther services that benefit a recipient tward better health utcmes. Level 2 adult mental health case management is generally delivered in the cmmunity (i.e., wherever the recipient lives, wrks, etc.), and builds upn available supprts in the individual s natural envirnment and has a cre fcus n recvery and whle health. Level 2 adult mental health case management services are cmprehensive, linked and driven by the individual s treatment r service plan and include: 1. An assessment f the eligible individual which includes histry-taking, a needs and strengths assessment, and infrmatin gathered frm ther current r frmer treatment prviders and family members as available. The assessment shuld address the individual s circumstances, strengths and needs that impairs their ability t achieve persnal gals independently in the fllwing areas: 1 P age Medical / Psychiatric Histry Mental Health and Substance Abuse Activities f Daily Living

2 TennCare Level 2 Adult Mental Health Case Management Definitin Vcatinal/ Educatinal Scial / Family Supprts Leisure / Recreatin Legal Issues Cmmunity Resurces (e.g., health care, educatinal, fd assistance, religius and cultural, etc.) Financial Assistance Husing Transprtatin 2. Develpment f a specific treatment r service plan which addresses identified needs frm the assessment elements utlined abve in subsectin ne will match the cnsumer s strengths and needs and link t specific cmmunity resurces. 3. Referral, linkage, and crdinatin t services, including: medical, psychiatric, emplyment, educatinal, scial and natural supprts benefits fr which they are eligible, husing, transprtatin, and cmmunity resurces. 4. Fllw-up and Mnitring in rder t assess the effective implementatin f the service plan as well as prvide an n-ging assessment f needs related t their physical and behaviral health and prgress. 5. The ultimate gal f Level 2 Case Management is t empwer individuals t live successfully in the cmmunity utilizing their natural supprts. 2 P age

3 TennCare Level 2 Adult Mental Health Case Management Medical Necessity Criteria Nvember 2015 Prgram Descriptin Level 2 Case Management is a level f Adult MHCM-Tennessee services supplied thrugh an individual apprach. Services at this level are geared tward persns with diagnsable mental illnesses wh have nt successfully engaged in cmmunity-based mental health and/r medical services. Individuals receiving this level f service typically fail t keep appintments and ften have failed t schedule any appintments. Cnsequently, cnsumers f Level 2 are extremely incnsistent in their access t and utilizatin f cmmunity-based services resulting in ptentially unnecessary usage f high-end services such as emergency departments. Cnsumers f Level 2 further lack natural supprts. If identifiable, access t and/r engagement f thse supprts is extremely unpredictable, at best. A single case manager prvides individual Level 2 Adult MHCM- Tennessee services, in cntrast t the team-apprach f Level la. The case manager s sle respnsibility is t prvide case management services fr the cnsumer which invlves client cntact, mnitring, and crdinatin f necessary services that aid the service recipient in mving tward recvery. The case manager des nt and will nt prvide direct clinical services r services fr the cnsumer utside f thse activities apprved as case management services in accrdance with the TennCare Cntractr Risk Agreement. Admissin Criteria Admissin t Level 2 Adult MHCM-Tennessee will be based n medical necessity and must meet medical necessity criteria per TennCare Rule including the recmmendatin f a licensed physician wh is treating the member r ther licensed healthcare prvider practicing within the scpe f his r her license wh is treating the member, t include the member s treatment team that are lcated at the prvider site. In additin, admissin criteria shuld include the fllwing key cmpnents: The service recipient: Level 2 Mental Health Case Management Medical Necessity Criteria FINAL 1

4 Has a diagnsable mental illness that impairs his/her ability t functin within the cmmunity; AND 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. These members exhibit behavirs t suggest that they are nt able t crdinate their wn treatment resulting in frequent readmissins. These members require educatin in the areas f mental health/physical health t engage in treatment and adhere t appintments; AND Needs assistance utilizing r accessing behaviral health, medical, and/r cmmunity-based services t functin in the cmmunity as necessary fr recvery. In additin, persns admitted t Level 2 Adult MHCM: Have had at least ne (1) psychiatric hspitalizatin, residential treatment r CSU discharge within the last six (6) mnths. OR Due t his r her mental illness, the service recipient meets any tw f the fllwing cnditins with service gal being t impact quality f life in areas f recvery: Demnstrates a pattern f incnsistency r failure in scheduling r keeping appintments at an utpatient facility in rder t meet the needs related t the mental/physical health symptms f his/her mental and/r physical illness within the last six (6) mnths. Demnstrates a pattern f incnsistency in his/her adherence t prescribed behaviral health r medical treatment within the last six (6) mnths. Has received a medicatin adjustment in the previus six mnths due t instability f symptms and has develped additinal cnditins which require assessment, planning, linkage and referral mnitring and fllw up. Has had at least tw psychiatrically driven presentatins at an ER within the last six (6) mnths. Level 2 Mental Health Case Management Medical Necessity Criteria FINAL 2

5 Demnstrates a pattern f incnsistency r failure t identify and/r cmmunicate with natural supprts t assist with access r utilizatin f needed medical, educatinal, scial, r ther services within the last six (6) mnths. Has experienced clinically significant changes in scial factrs in the last (12) mnths leading t decreased ability t functin independently r within current supprt system due t the individual s mental health needs, as indicated within the referral dcumentatin. Invlvement with law enfrcement r the criminal justice system within the last six (6) mnths. Individual is unable t btain r sustain emplyment due t their mental health cnditin within the last 6 mnths. Individual has experienced a disruptin in previusly stable husing within the past 6 mnths, as a direct result f symptms related t the individual s mental health cnditin. Individual exhibits financial mismanagement which impacts r is impacted by their symptms within the past 6 mnths. Based n the criteria selected, the member shws functinal deficits, that can be impacted by Case Management services, in ne r mre f the fllwing applicable dmains: Medical / Psychiatric Mental Health / Substance Abuse Activities f Daily Living Vcatinal / Educatinal Scial / Family Supprts Leisure / Recreatin Legal Issues Level 2 Mental Health Case Management Medical Necessity Criteria FINAL 3

6 Cmmunity Resurces Financial Assistance Husing Transprtatin Exclusin Criteria Any f the fllwing criteria are sufficient fr exclusin frm this level f care: Member is receiving nn-team based case management, CTT, CCFT, r PACT services frm anther prvider at the time f the request, unless the service in questin is being used in a transitinal manner; r Severity f psychscial impairment due t a behaviral health cnditin requires higher intensity f interventin than can be prvided thrugh Level 2 mental health case management services; r Member is receiving Supprted Husing r Enhanced Supprted Husing services, except in the fllwing circumstances: Case Management is necessary t enhance placement stability during a transitin prcess, OR Case Management is necessary t enhance placement stability fr medically fragile r medically and/r psychiatrically cmplex members wh require extensive crdinatin with medical and/r behaviral health prviders, OR Case Management is necessary t prvide increased linkage t family supprts in an effrt t re-engage in family relatinships. Member refuses case management services. Level 2 Mental Health Case Management Medical Necessity Criteria FINAL 4

7 Cntinuatin Criteria Cmpnents f cntinued stay fr the service recipient in Level 2 Mental Health Case Management wuld include the fllwing: The individual cntinues t meet admissin criteria OR The individual has made measureable prgress n service plan gals, but cntinues t demnstrate a need fr supprt, advcacy and mnitring in rder t access resurces as dcumented in the recrd (i.e., service ntes, assessment tls, ther utcmes based measurement tls ), There is demnstrated meaningful benefit fr the cntinuatin f Case Management. Fr the cntinuatin t be meaningful there must be evidence that Case Management has a psitive impact n mving twards recvery and demnstrates gains as evidenced in treatment plan. Benefit f case management can be generalized at the cnclusin f the service. Based n the criteria selected, the member shws functinal deficits, that can be impacted by Case Management services, in ne r mre f the fllwing applicable dmains: Medical / Psychiatric Mental Health / Substance Abuse Activities f Daily Living Vcatinal / Educatinal Scial / Family Supprts Leisure / Recreatin Legal Issues Cmmunity Resurces Level 2 Mental Health Case Management Medical Necessity Criteria FINAL 5

8 Financial Assistance Husing Transprtatin OR Individual may have demnstrated relative stability in their functining in the previus six mnths where there have been dcumented attempts t lessen mental health supprts, but has a dcumented histry f relapse and deteriratin in the absence f mental health supprts, as evidenced by: Individual cntinues t btain services frm multiple prviders/agencies, which may include medical, psychiatric, scial, educatinal, r vcatinal; and their cnditin is such that crdinatin f care and active invlvement f mental health case management is essential fr a psitive treatment utcme. Individual has multiple cmplicating factrs, (i.e., medical, scial, vcatinal, financial) which require n-ging assistance in rder t avid deteriratin and assist the individual in maintaining cmmunity tenure. Individual cntinues t be in need f additinal services, but has struggled t access r maintain thse services (i.e., individual cntinues t demnstrate a lack f scial and persnal resurces needed fr recvery.) Mnitring activities prvided by mental Level 2 Mental Health Case Management Medical Necessity Criteria FINAL 6

9 health case management are necessary t ensure that the n-ging needs f the cnsumer are met in accrdance with the established care plan. As part f the cntinuatin criteria, individualized discharge planning fr Level 2 Adult Mental Health Case Management shuld be addressed. Discharge Criteria Discharge decisins will be based n a review f the client s prgress in the dmains referenced in the admissin / cntinuatin criteria. Discharge fr Level 2 service recipients wuld cnsider the fllwing criteria : Demnstratin f little t n prgress in meeting targeted gals fr 6 mnths, despite dcumented attempts t engage the individual in services. Refusal t participate in crdinatin f services t fr 3 cnsecutive mnths. Mvement ut f the state. Lss f cmmunity tenure thrugh lng-term incarceratin r the need fr skilled-nursing care, duplicatin with LTSS (CHOICES) case management. Met case management gals as identified in the service plan with n additinal needs identified that culd be impacted by case management. Level 2 Mental Health Case Management Medical Necessity Criteria FINAL 7