Residential Treatment Services for Children in the Dependency System Under Managed Care

Transcription

1 Residential Treatment Services for Children in the Dependency System Under Managed Care Residential Mental Health Treatment in Florida (Ch. 39 & 394 F.S.) March 10,

2 Presenter: Heather Allman, LCSW Agency for Health Care Administration

3 Training Objectives Provide an overview of the Statewide Medicaid Managed Care (SMMC) Program. Describe the difference between placement and treatment. Review the mental health system of care. Review the residential treatment referral and placement process for dependent children. 3

4 Statewide Medicaid Managed Care (SMMC) Long-term Care (LTC) program Statewide Medicaid Managed Care (SMMC) program Managed Medical Assistance (MMA) program 4

5 Statewide Medicaid Managed Care Regions Map Region 2 Holmes Jackson Region 1 W alton Bay Gulf Gadsden Leon W akulla Liberty Franklin Hamilton Madison Taylor Lafayette Baker Nassau Duval Clay Region 4 Dixie Alachua Putnam Flagler Levy Region 3 Citrus Marion Lake Volusia Seminole Region 7 Hernando Orange Region 5 Pasco Polk Osceola Region 6 Region 1: Escambia, Okaloosa, Santa Rosa, and Walton Region 2: Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon, Liberty, Madison, Taylor, Wakulla, and Washington Region 3: Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton, Hernando, Lafayette, Lake, Levy, Marion, Putnam, Sumter, Suwannee, and Union Region 4: Baker, Clay, Duval, Flagler, Nassau, St. Johns, and Volusia Region 5: Pasco and Pinellas Region 6: Hardee, Highlands, Hillsborough, Manatee, and Polk Region 7: Brevard, Orange, Osceola, and Seminole Region 8: Charlotte, Collier, DeSoto, Glades, Hendry, Lee, and Sarasota Region 9: Indian River, Martin, Okeechobee, Palm Beach, and St. Lucie Region 10: Broward Region 11: Miami-Dade and Monroe Hardee Manatee Highlands De Soto Sarasota Glades Charlotte Hendry Lee Region 8 Region 11 Collier St. Lucie Martin Palm Beach Broward Dade Region 9 Region 10 5

6 What is Placement? 65C (16), Florida Administrative Code defines out of home care to mean the placement of a child, arranged and supervised by the Department of Children and Families or its agent, outside the home of the child s custodial parent or legal guardian. This includes placement in licensed shelter, foster home, group home, Residential Treatment Center (including Statewide Inpatient Psychiatric Programs), and non-licensed relative/non-relative settings. 6

7 Residential Placement Responsibilities Children are placed by the Department of Children and Families (DCF) or their designated Community Base Care (CBC). Children placed by the department and funded in full or in part by state, Medicaid, or local matching funds shall be admitted only after they have on recommendation of the appropriate multidisciplinary team, been personally examined and assessed for suitability for residential treatment. (Rule 65-E9.008(4), Fla. Admin. Code) 7

8 What is Treatment? Treatment means the provision, coordination, or management of health care and related services by one or more providers, including the coordination or management of health care by a provider with a third party. 8

9 Residential Treatment Responsibilities Medicaid managed care plans or their subcontractor must have a process to participate in interagency staffings or school staffings that may result in the provision of behavioral health services to an enrolled child/adolescent. The managed care plan or their subcontractor must participate in such staffings upon request. (Attachment II, Exhibit II-A, Section V.A.1.a.(4).(d).(iii). 9

10 Residential Treatment Responsibilities (Continued) Managed care plans are responsible for recruiting and contracting with qualified providers of Therapeutic Group Care (TGC) and Statewide Inpatient Psychiatric Program (SIPP) services. Plans are required to enter into contracts with a sufficient number of providers to deliver all covered services to enrollees and ensure that each covered service is provided promptly and is reasonably accessible. 10

11 Residential Treatment Responsibilities (Continued) Managed care plans develop their own utilization review process for service authorization. Managed care plans are required to maintain a provider complaint system allowing providers to dispute any aspect of the plans administrative functions, including claims. 11

12 Residential Treatment Responsibilities (Continued) Managed care plans are required to respond to standard authorization requests as expeditiously as the enrollee s health condition requires and within no more than seven (7) days and expedited requests within 48 hours. Managed care plans must notify providers and give the enrollee written notice of any decision to deny a service authorization request, or to authorize a service in an amount, duration or scope that is less than requested. 12

13 Mental Health Services in a System of Care Screening/Assessment Wraparound In Home Residential School Based Respite Crisis 13

14 Indications that Out-of-Home Treatment is Appropriate Services and supports have been tried in less restrictive settings. The child or youth has a significant mental health and/or co-occurring mental health and substance abuse disorder that significantly impairs their ability to function in the community. Youth s mental health condition has a high level of acuity (i.e., multiple Baker Act admissions in a short period of time). 14

15 Definition for Severe Emotional Disturbance (s , F.S.) Child or adolescent who has serious emotional disturbance or mental illness means a person under 18 years of age who: Is diagnosed with a mental, emotional, or behavioral disorder per the DSM Exhibits behaviors that substantially interfere with or limit his or her role or ability to function in the family, school, or community, when behaviors are not considered to be a temporary response to a stressful situation. 15

16 Criteria for Referral for Therapeutic Group Care and Statewide Inpatient Psychiatric Program Services Before a dependent child can be referred for a suitability assessment, the Community Based Care Lead Agency Service Worker will review the child s current condition: Does the child have an emotional disturbance that requires the intensity and restrictiveness of treatment offered in a residential treatment center? 16

17 Access to Care for Dependent Children When the Department of Children and Families (DCF) or the Community Based Care (CBC) believes a child in custody is emotionally disturbed and may need residential treatment, an examination and suitability assessment must be conducted before placement of the child (6)(b). 17

18 Access to Care for Dependent Children Section (5) F.S. Provides criteria for placement of children in Department s legal custody Outlines steps to achieve placement in a residential treatment center Provides for regularly scheduled reviews by treatment center, community based care lead agency, and the courts 18

19 Qualified Evaluator The suitability assessment must be conducted by a qualified evaluator who is appointed by the Agency for Health Care Administration. A qualified evaluator must: Be a psychiatrist or psychologist licensed in Florida. Have at least 3 years experience in the diagnosis and treatment of serious emotional disturbances in children and adolescents; and Have no actual or perceived conflict of interest with an inpatient facility or residential treatment center or program. 19

20 The Suitability Assessment Suitable for residential treatment or suitability means a determination concerning a child or adolescent with an emotional disturbance (as defined in (5)) or serious emotional disturbance (as defined in (6)) that each of the following criteria is met: The child requires residential treatment; The child is in need of a residential treatment program and is expected to benefit from mental health treatment; and An appropriate, less restrictive alternative to residential treatment is unavailable. 20

21 Suitability Assessment Recommendations The Qualified Evaluator must specify one of the following: Inpatient Residential Residential Therapeutic Group Home Residential Not Recommended. 21

22 Overview of the Pre-Admission Process Multidisciplinary Team Staffing Assessment of Suitability Court Hearing Referral for Residential Services Authorization 22

23 Vignette Peter Parker is a 15 year old dependent child in the care and custody of the Department of Children and Families. Logan, Peter s dependency case manager with the local community based care agency, coordinates services for Peter and his Aunt May. Peter sees a therapist, Ms. Watson, weekly for individual and family counseling for depression and post-traumatic stress disorder. Peter is prescribed medication by his psychiatrist Dr. Grey but continues have emotional outbursts and is unable to focus on his schoolwork. Peter has started to dissociate. Peter has been placed with his Aunt May who discusses with Logan that she is concerned that Peter s symptoms aren t improving; she reports that Peter s depression has worsened since his Uncle Ben was tragically killed. 23

24 Referral and Placement Process for Dependent Children Judicial Rule Criteria Met? Suitability Assessment referral to Magellan Determination of Need Suitability Assessment done Suitable for Residential Treatment? File motion for placement Copies of SA to all parties Link to Community Services Notice court and all parties Link to Community Services 24

25 Referral and Placement Process for Dependent Children (continued) Judicial Rule File motion with court to place Court sets status hearing All parties agree? Court sets placement hearing 10 working days Court approves or denies Motion Why suitable QE findings/ report Agreement of all parties? Child may attend (in person or by phone) Court may approve Child may attend (in person or by phone) Child placed in least restrictive setting to meet needs 25

26 Referral and Placement Process for Dependent Children (continued) Placement and Review Court approves initial placement Placement identified & child placed Review hearing in 90 days Treatment plan in 10 days Provider 30 day review 90 day Suitability Assessment Treatment requires prior authorization Treatment requires continued stay reviews ongoing Suitability Assessment can recommend continued stay or not If not, step down. *A court order for placement does not determine medical necessity. 26

27 Referral and Placement Process for Dependent Children (continued) Review and Discharge 90 day review hearing Approve continued placement? Court order; place child in less restrictive setting Court approved continued placement 90 day Reviews: 90-day SA by QE continue until child is stepped down from residential treatment level 90-day court reviews continue until child is stepped down from residential treatment level Discharge Criteria Child successfully completes treatment between 90- day reviews Qualified Evaluator recommends step down Court orders step down to less restrictive placement 27

28 What Happens When Residential Treatment Is Not Recommended The multidisciplinary team reconvenes and discusses community-based supports and services for the child or youth. The court has the authority to order the residential treatment of a dependent child in the custody of the department despite a contrary recommendation by the AHCA designated qualified evaluator if it affords the child the additional protections of the Baker Act. (Lee, Michael, and Traphofner, John. Memo to Mary Cagle, State Director of Children s Legal Services, Tallahassee, FL. March 2010.) 28

29 Discharge Planning Discharge Criteria for Residential Treatment The recipient has received maximum benefit from his or her present plan of care; The recipient has not benefitted from a reasonable course of treatment; A discharge plan had been established, and the aftercare services plan includes family or family surrogate and the district mental health office; or Severe medical problems have arisen that cannot be managed by the facility. The discharge plan must be provided to the parent, legal guardian, guardian ad-litem, and DCF at least 30 days before the proposed discharge date. (65E-9.011) 29

30 Discharge Planning Standards of Good Care Discharge placement is identified at admission. CBC and the managed care plan are kept informed & participate in discharge planning from the time of admission. The child is given opportunities to practice skills with family at home as part of discharge planning (e.g., therapeutic passes). Appropriate referrals are made for follow-up treatment (continuity of treatment). 30

31 Discharge Planning Standards of Good Care Clinical aftercare recommendations specify the level of structure and supervision needed by the child and what services and supports are necessary to address specified issues. Discharges occurs when child is ready to return safely to the community and continue active treatment in a less restrictive setting. Child or adolescent is assisted in working through termination process following demonstration of ability to self-manage and achievement of other treatment goals. 31

32 Vignette (Continued) After Peter s 90 day review, the provider issues the final discharge plan to the Aunt May, Logan, Peter s guardian ad-litem, and DCF at least 30 days before the proposed discharge date. The provider and Peter s managed care plan work with Logan and Aunt May to institute the provisions of Peter s discharge plan. A referral is made for Peter to receive intensive counseling and medication management services from providers in his plan s network. 32

33 What to do when there is a problem The Agency has established a centralized hub to report all managed care related issues and complaints. This is the Agency s process for identifying, trending, and tracking all issues and complaints to satisfactory resolution. The hub is utilized by providers, stakeholders and recipients to request assistance with managed care issues and complaints. 33

34 What to do when there is a problem? If you have a complaint about Medicaid Managed Care services, please complete the online form found at: If you need assistance completing this form or wish to verbally report your issue, please contact your local Medicaid area office. Find contact information for the Medicaid area offices at: 34

35 Questions 35