Arkansas Medicaid RSPMI Rehab Day Services for Adults

Transcription

1 Arkansas Medicaid RSPMI Rehab Day Services for Adults presented by: Kerri Brazzel Patricia Gann

2 Disclaimer This training does not contain a legal description of all aspects of Medicaid clinical record documentation regulations. It is a practical guide for providers who participate in the Medicaid Program. The information provided is not intended to be allinclusive or otherwise limit the inquiry and consideration applicable to decisions regarding a beneficiary s rehabilitation needs. Guidelines and procedures in this training are based on requirements of States and Federal law. Thus the guidelines and procedures are subject to change if the requirements of the law or accrediting organization change. Where there is conflict between this edition of the training and a subsequent notification of a modification to a policy or procedure, the information in the subsequent notification shall prevail. 2

3 Regulations/ Service Definitions 3

4 Rehabilitative Day Services for Persons H2017 SERVICE: Rehabilitative Day Service for Persons Ages DEFINITION: An array of face-to-face rehabilitative day activities providing a preplanned and structured group program for identified beneficiaries that improve emotional and behavioral symptoms of youth diagnosed with childhood disorders, as distinguished from the symptom stabilization function of acute day treatment. These rehabilitative day activities are person-and family-centered, age-appropriate, recovery based, culturally competent, must reasonably accommodate disability, and must have measurable outcomes. These activities are designed to assist the beneficiary with compensating for or eliminating functional deficits and interpersonal and/or environmental barriers associated with their mental illness. The intent of these services is to enhance a youth's functioning in the home, school, and community with the least amount of ongoing professional intervention. Skills addressed may include: emotional skills, such as coping with stress, anxiety, or anger; behavioral skills, such as positive peer interactions, appropriate social/family interactions, and managing overt expression of symptoms like impulsivity and anger; daily living and self-care skills, such as personal care and hygiene, and daily structure/use of time; cognitive skills, such as problem solving, developing a positive self-esteem, and reframing, money management, community integration, understanding illness, symptoms and the proper use of medications; and any similar skills required to implement a beneficiary's master treatment plan. 4

5 Adult Rehabilitative Day Services H2017 SERVICE: : Adult Rehabilitative Day Service DEFINITION: An array of face-to-face rehabilitative day activities providing a preplanned and structured group program for identified beneficiaries that aimed at long-term recovery and maximization of self-sufficiency, as distinguished from the symptom stabilization function of acute day treatment. These rehabilitative day activities are person and family-centered, recovery based, culturally competent, provide needed accommodation for any disability and must have measurable outcomes. These activities assist the beneficiary with compensating for or eliminating functional deficits and interpersonal and/or environmental barriers associated with their chronic mental illness. The intent of these services is to restore the fullest possible integration of the beneficiary as an active and productive member of his/her family, social and work community and/or culture with the least amount of ongoing professional intervention. Skills addressed may include: emotional skills, such as coping with stress, anxiety, or anger; behavioral skills, such as proper use of medications, appropriate social interactions, and managing overt expression of symptoms like delusions or hallucinations; daily living and self-care skills, such as personal care and hygiene, money management, and daily structure/use of time; cognitive skills, such as problem solving, understanding illness and symptoms, and reframing; community integration skills and any similar skills required to implement a beneficiary's master treatment plan. 5

6 Rehabilitative Day Services for Adults (Service Definition continued) DAILY MAXIMUM UNITS THAT MAY BE BILLED: 24 WEEKLY MAXIMUM OF UNITS THAT MAY BE BILLED: 120 PRIOR AUTHORIZATION REQUIRED ALLOWABLE PLACES OF SERVICE: Office (11); Assisted Living Facility (13); Group Home (14); Other locations (99) (churches, community centers, space donated solely for clinical services, and appropriate community locations tied to the beneficiary s treatment plan) MAXIMUM PARAPROFESSIONAL STAFF TO CLIENT RATIOS: 1:15 ratio maximum with the provision that client ratio must be reduced when necessary to accommodate significant issues related to acuity, developmental status and clinical needs. AGE GROUP(S): 18-20; 21 and Over 6

7 Adult Rehabilitative Day Services (Service Definition continued) Documentation Requirements: Date of service Start and stop times of actual program participation by beneficiary Place of service Client diagnosis necessitating rehabilitative day activities Behavioral observations Document how rehabilitative day activities used address goals and objectives from the master treatment plan Beneficiary's participation and response to the rehabilitative day activities Staff signature/credentials Supervising staff signature/credentials/date of signature(s) A weekly summary, signed by a Mental Health Professional (the supervising MHP, if applicable), describing rehabilitative day activities provided and the beneficiary's progress or lack of progress in achieving the treatment goal(s) and established outcomes to be accomplished through participation in rehabilitative day service. 7

8 Adult Day Rehabilitative Services NOTES AND COMMENTS: Rehabilitative Day services do NOT include vocational services and training, academic education, personal care or home health services, purely recreational activities and may NOT be used to supplant services which may be obtained or are required to be provided by other means. Providers may bill for services only at times during which beneficiaries participate in program activities. Providers are expected to sign beneficiaries in and out of the program to provide medically necessary treatment therapies. However, in order to be claimed separately, these therapies must be identified on the Master Treatment Plan and serve a treatment purpose which cannot be accomplished within the day treatment setting. 8

9 Adult Rehabilitative Services Daily Limit of Beneficiary Services Medicaid Beneficiaries will be limited to a maximum of eight hours per 24 hour day of outpatient services with the exception of Crisis Intervention, Crisis Stabilization Intervention by Mental Health Professional and Crisis Stabilization Intervention by Mental Health Paraprofessional. Beneficiaries will be eligible for an extension of the daily maximum amount of services based on a medical necessity review by the contracted utilization management entity (See Section for details regarding extension of benefits). 9

10 Adult Rehabilitative Services Services Available to Residents of Long Term Care Facilities The following RSPMI services may be provided to residents of nursing homes and ICF/MR facilities who are Medicaid eligible when the services are prescribed according to policy guidelines detailed in this manual: A. Mental Health Evaluation/Diagnosis, B. Psychological Evaluation, C. Pharmacologic Management by Physician, D. Master Treatment Plan, E. Periodic Review of Master Treatment Plan, F. Interpretation of Diagnosis, G. Individual Psychotherapy, H. Crisis Intervention. Services provided to nursing home and ICF/MR residents may be provided on- or off-site from the RSPMI provider if allowable per the service definition. Some services may be provided in the long-term care (LTC) facility, if necessary. 10

11 Adult Rehabilitative Day Services Documentation The RSPMI provider must develop and maintain sufficient written documentation to support each medical or remedial therapy, service, activity or session for which Medicaid reimbursement is sought. This documentation, at a minimum, must consist of: A. Must be individualized to the beneficiary and specific to the services provided, duplicated notes are not allowed. B. The date and actual time the services were provided (Time frames may not overlap between services. All services must be outside the time frame of other services.), C. Name and credentials of the person, who provided the services, D. The setting in which the services were provided. For all settings other than the provider s enrolled sites, the name and physical address of the place of service must be included, E. The relationship of the services to the treatment regimen described in the plan of care and F. Updates describing the patient s progress and G. For services that require contact with anyone other than the beneficiary, evidence of conformance with HIPAA regulations, including presence in documentation of Specific Authorizations, is required. Documentation must be legible and concise. The name and title of the person providing the service must reflect the appropriate professional level in accordance with the staffing requirements found in Section

12 Rehabilitative Services for Adults Documentation (continued) Every individual receiving Rehabilitative Day Services must have both daily notes and a weekly summary documented in the medical record. The weekly summary must be signed by a Mental Health Professional (MHP) and include a description of therapeutic activities provided and the beneficiary s progress or lack of progress in achieving the treatment plan goal(s) and established outcomes to be accomplished. Additionally, if a Mental Health Paraprofessional (MHPP) documents and signs the daily notes, the supervising MHP must sign the weekly summary. The supervising MHP s signature indicates that the MHP has supervised and approves of the daily services provided by the MHPP. 12

13 Rehabilitative Day Services for Adults Person and Family Centered Focus Required by regulation Specifically mentioned and defined 13

14 Rehabilitative Day Services for Adults H2017 SERVICE: Adult Rehabilitative Day Service DEFINITION: An array of face-to-face rehabilitative day activities providing a preplanned and structured group program for identified beneficiaries that aimed at long-term recovery and maximization of self-sufficiency, as distinguished from the symptom stabilization function of acute day treatment. These rehabilitative day activities are person- and family-centered, recovery based, culturally competent, provide needed accommodation for any disability and must have measurable outcomes. These activities assist the beneficiary with compensating for or eliminating functional deficits and interpersonal and/or environmental barriers associated with their chronic mental illness. The intent of these services is to restore the fullest possible integration of the beneficiary as an active and productive member of his/her family, social and work community and/or culture with the least amount of ongoing professional intervention. Skills addressed may include: emotional skills, such as coping with stress, anxiety, or anger; behavioral skills, such as proper use of medications, appropriate social interactions, and managing overt expression of symptoms like delusions or hallucinations; daily living and self-care skills, such as personal care and hygiene, money management, and daily structure/use of time; cognitive skills, such as problem solving, understanding illness and symptoms, and reframing; community integration skills and any similar skills required to implement a beneficiary's master treatment plan. 14

15 Rehabilitative Day Services for Adults Rehabilitative Day Services Must: Be recovery based Have measurable outcomes 15

16 Rehabilitative Day Services for Adults H2017 SERVICE: Adult Rehabilitative Day Service DEFINITION: An array of face-to-face rehabilitative day activities providing a preplanned and structured group program for identified beneficiaries that aimed at long-term recovery and maximization of self-sufficiency, as distinguished from the symptom stabilization function of acute day treatment. These rehabilitative day activities are person- and family-centered, recovery based, culturally competent, provide needed accommodation for any disability and must have measurable outcomes. These activities assist the beneficiary with compensating for or eliminating functional deficits and interpersonal and/or environmental barriers associated with their chronic mental illness. The intent of these services is to restore the fullest possible integration of the beneficiary as an active and productive member of his/her family, social and work community and/or culture with the least amount of ongoing professional intervention. Skills addressed may include: emotional skills, such as coping with stress, anxiety, or anger; behavioral skills, such as proper use of medications, appropriate social interactions, and managing overt expression of symptoms like delusions or hallucinations; daily living and self-care skills, such as personal care and hygiene, money management, and daily structure/use of time; cognitive skills, such as problem solving, understanding illness and symptoms, and reframing; community integration skills and any similar skills required to implement a beneficiary's master treatment plan. 16

17 Rehabilitative Day Services for Adults Purpose of Rehabilitative Day Services To assist the beneficiary with compensating for or eliminating functional deficits and interpersonal and/or environmental barriers associated with their chronic mental illness To restore the fullest possible integration of the beneficiary as an active and productive member of his/her family, social and work community and/or culture with the least amount of ongoing professional intervention 17

18 Rehabilitative Day Services for Adults What can Rehab Day Activities include? Emotional skills, such as coping with stress, anxiety, or anger Behavioral skills, such as proper use of medications, appropriate social interactions, and managing overt expression of symptoms like delusions or hallucinations Daily living and self-care skills, such as personal care and hygiene, money management, and daily structure/use of time Cognitive skills, such as problem solving, understanding illness and symptoms, and reframing Community integration skills and any similar skills required to implement a beneficiary's master treatment plan 18

19 Rehabilitative Day Services for Adults Active Treatment-Pre-Planned and Structured: Active treatment and participation is required. Billable criteria is not met when beneficiaries are: Resting and/or sleeping Milling about Chatting with peers Playing isolative games Watching television/movies Hanging around outside smoking cigarettes Is there a schedule of activities, classes, etc.? 19

20 Rehabilitative Day Services for Adults Rehab Day Services Do NOT Include: Vocational services and training Academic education Personal care or home health services Purely recreational activities May NOT be used to supplant services which may be obtained or are required to be provided by other means 20

21 Rehabilitative Day Services for Adults Additional Considerations: The need for structure is not a medically necessary reason for enrolling a beneficiary in Rehabilitative Day Services. Enrolling beneficiaries in Rehabilitative Day Services for the purpose of having them conveniently available to sign in and out for other services is not a medically necessary reason for enrolling a beneficiary in Rehabilitative Day Services. 21

22 Rehabilitative Day Services for Adults Staff Interaction and Supervision Required: Examples of non-billable Rehab Day times: Passively observing beneficiaries Beneficiaries watching a movie and no treatment occurring Academic tutoring and educational (three R s) activities Smoke breaks with beneficiaries 22

23 Rehabilitative Day Services for Adults Differentiating Between Non-Treatment Activities and Rehab Day Activities Examples Taking a beneficiaries on outing for fun versus a highly structured activity where specific behavioral objectives are to be practiced and evaluated. Playing games during free time versus practicing targeted behaviors in a game setting The big question is: Is the activity designed and structured to address a specific functional deficit or symptom? 23

24 Rehabilitative Day Services for Adults Does Your Rehab Day Program Differ from Adult Day Care? If so, an observer would be able to identify: The functional deficits or diagnosis-specific symptoms being treated for each individual beneficiary. A milieu structure that differs from supervised residential/day care program. Activities and interventions that require staff members to be trained in the treatment of mental illness. 24

25 Rehabilitative Day Services for Adults If asked to debrief following an activity, what do your beneficiaries report? Do they say only things like: Do they say I am learning: had fun played cards hung out with friends saw the elephant at the zoo made crafts smoked and ate lunch about my medications and how to take them how to keep up with appointments my triggers to relapse what I can do when I am getting anxious or stressed 25

26 Rehabilitative Day Services for Adults Interventions During Rehab Day Services (Examples): Intervening in dangerous behavior or situation Addressing symptomatic behaviors that disrupt the treatment milieu Helping a beneficiary understand or follow instructions Reminding beneficiary to follow the rules Encouraging participation Chatting with a beneficiary Inactive observation of beneficiary 26

27 Rehabilitative Day Services: Medical Necessity Copyright 2014 ValueOptions. All rights reserved. 27

28 Basics of Medical Necessity Personnel with appropriate level of licensure must render service Service documented is in compliance with service definition Beneficiary should have a DSM/ICD mental health diagnosis Beneficiary should have sufficient cognitive ability to benefit 28

29 DSM or ICD Diagnosis Diagnosis alone is not sufficient Should include: Diagnosis (DSM or ICD Mental Health Diagnosis) Supporting behaviors and/or symptoms Functional impairments 29

30 Active Treatment/Participation Client must be an active participant Documentation must be clear in reference to the beneficiary s participation in treatment Possible Causes for Concern: Non-compliance, non-participation Catatonia and other diagnoses that may prevent participation Sleeping during treatment program Staying outside smoking Severe Mental Retardation Insufficient cognitive ability to benefit 30

31 Sufficient Cognitive Ability Does the beneficiary have sufficient cognitive ability to benefit from or participate in treatment? Possible Causes for Concern: Dementia (may be appropriate in early stages) Mental Retardation (Moderate or severe) Autism (substantiate mental health diagnosis apart from PDD) Other (intoxication, severe disorganized thinking, etc.) Length of services (ability to sustain attention for length of service documented) 31

32 Documentation Copyright 2014 ValueOptions. All rights reserved. 32

33 Disclaimer These examples are meant to be informational only and do not meet all service definition requirements for services indicated. Times, dates, goals and objectives, etc. are excluded for the purpose of brevity in the examples. 33

34 Service Definition? Attempted to call Sue to reschedule appointment but no one home. Left message. Reviewed treatment plan and wrote up monthly documentation of what services have been provided without beneficiary. John attended NA/AA meeting with MHPP. He was very enthusiastic about meeting. Jane came in to pick up check. We discussed her plans for the weekend. She will go to the movies with friends and go to her son s house for a cookout. 34

35 Service Definition? Reviewed steps with client on how to catch bus from her apartment to the store including: arriving at the bus stop ten minutes ahead of time, showing her pass to the driver, sitting where she feels comfortable, having her bus schedule available, familiarizing her with names of streets and keeping an eye out for stops ahead of hers for the apartment and the store. 35

36 Professional Group Intervention: Facilitated group interaction and process in relations to dealing with anxiety. Used interactions between group members to encourage processing of situational anxiety, solution focused feedback and group support. Response: Sue shared her experiences last week with anxiety when talking with the job placement expert at workforce office. Was able to utilize feedback from other group members to identified strategies to reduce anxiety. Was encouraged to hear that others had the same experience and stated that this helped her know that she should keep working toward her goal. Progress: Sue was anxious during discussion but did not have to leave group due to panic attack during this session as she has in the past. Plan: Sue plans to continue practicing new skills and report back to the group. Continue weekly group sessions. 36

37 Professional Group Intervention: Used group process of this cohesive group to address negative thought patterns and self defeating messages. Encouraged group to provide constructive feedback to members when negative self talk was noted. Offer alternative positive affirmations. Response: Sara was able to identify negative self talk by another member and constructively offered reframing of the situation. Received positive feedback from member and she smiled and sat up taller in her chair. Progress: This was the first time that Sara has offered feedback to another group member. She was very engaged in the group. Stated that it felt safe here and she was gaining confidence to take skills outside of clinic setting. Plan: Sara agrees to share her experience from her homework of riding the bus again in the next two weeks to practice skills. Will return to group in two weeks. 37

38 Paraprofessional Intervention: Role played some possible scenarios as taught by clinician in contacting agencies for information and prompted use of coping strategies when she became anxious. Response: Sue was able to role-play scenarios and to resolve anxiety using visualization. Progress: Sue reports that she called benefits counseling services and was able to get some information about her benefits through that agency. But did not make an appointment because she was anxious about the process. Plan: Sue agreed that she would call again this week and set up an appointment using skills we reviewed. Will check in with her next week to see if she has followed through. 38

39 Paraprofessional Intervention: Assisted Sara in implementing skills needed to go to the store without having to call an ambulance. Prompted her to use skills she had learned in therapy including thought stopping and critical thinking to evaluate if fears were rational or irrational. Response: Sara states that she was able to stop her obsessive thoughts and evaluate whether her fears were rational or irrational. Decided that they were not rational but was not able to follow through with going into the store this week. Progress: Sara was able to go to the store parking lot last week, but became very anxious when she got out to the car. Had to drive back home without the milk and bread she needed. She made no further attempts. Plan: Sara will go back to the store this week and will use techniques that she has practiced to go into the store. MHPP will meet her at the store parking lot to help her implement skills. 39

40 Rehab Day Intervention: Facilitated scheduled rehab day activities today including medication identification and compliance, health living habits and hygiene. Utilized structured group and interactive activities to assist beneficiaries in learning identified skills. Behavioral Observations: Autumn began a new medication this week. Appeared sleepy at times but was able to focus and participate in activities. She interacted appropriately with staff and other members most of the time. She did have two episodes when she was talking to her dead mother. But responded to prompts from staff and hallucinations cleared. Progress: Medications as still being adjusted and Autumn continues to live in the group home due to episodes of severe auditory and visual hallucinations. She knows the names of her medications and with some prompts is taking a bath and putting on clean clothes. Sleep at night continues to be poor due to reported voices and seeing her dead mother. Plan: Continue daily group and class activity to improve competence in daily living skills and so she can live more independently. 40

41 Questions? 41