ICG COMMUNICATION FORUM

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ICG COMMUNICATION FORUM

• Seth Harkins, EdD, Director ICG Program
• Bill White, LCSW, Clinical Director Illinois
  Mental Health Collaborative for Access and Choice
• December 18, 2008

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Goals for Todays Webcast

• To update residential and SASS providers on
  changes in the ICG program (unbundling of rates,
  care managers and SASS roles, Annual Reviews
• To provide an overview of Rule 132 and how it
  applies to the ICG program
• To clarify certain ICG procedures (Family income
  requirement, UIRs, Quarterly Reports, Annual
  Reviews, 94R and Medicaid eligibility)

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Why Unbundling ?

• Rule 132 Required
• Fee for service billing categories
• Enhanced service tracking
• Survey data regarding RTC services
• Clinically-focused and family centered provision
  of care
• Consumer-focused
• Focus on recovery and resiliency
• Emphasis on skill building in natural
  environments

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Fee for Service Categories

• Case management client centered
• Case management mental health
• Case management transition and linkage
• Community residential support individual
• Community residential support group
• Crisis intervention

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Fee for Service Categories

• Mental health assessment
• Psychological evaluation
• Psychotropic medication administration
• Psychotropic medication monitoring
• Psychotropic medication training
• Therapy/individual
• Therapy/group
• Therapy/family
• Treatment planning

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Fee for Service Categories Group C Services (Non
Medicaid)

• Oral interpretation and sign language
• Job finding
• Job retention
• Job Leaving/termination
• Vocational assessment
• Vocational engagement
• Vocational services

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What Did We Learn from the Fee for Service Survey

• Survey Monkey data collected in April and May
• Incomplete data led to further surveying
• Trends noted 1) community support residential
  individual and group varied considerably 2)
  limited vocational services reported 3)
  individual, group, and family therapy tended to
  below for clients requiring intensity of
  services 4) case management services were
  relatively low, particularly transition and
  linkage, averaging one hour a month 5) various
  ratios of MHPs to RSAs.

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What Did We Learn from the Fee for Service Survey?

• Clinical standards need to be established.
• Increased provisions of case management services
  at certain times to facilitate individualized
  care and transition to home and the community
  (e.g. case management transition and linkage).
• Two hours per week of individual therapy provided
  by QMHP is considered a minimum standard.
• Three hours per week of group therapy facilitated
  by a QMHP is considered a standard.
• One hour per week of family therapy provided by a
  QMHP is considered a standard.
• For clients ages 16 21 vocational services
  should be provided at least one hour per week.

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How Does Rule 132 Apply?

• Billing will be according to fee for service
  categories and service definitions
• An objective is to increase FFP so that Illinois
  receives enhanced Medicaid reimbursement
• Increased Medicaid eligibility
• 94R

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Fee for Service Billing

• During FY2009 residential providers will be paid
  their Illinois Purchase Care Review Board rate.

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Fee for Service Billing

• Residential providers will be required to make
  application for RTC clients eligible for
  Medicaid under 94R.
• It will be important for residential providers to
  work with SASS-ICG workers and parents to
  complete the necessary paperwork.
• It behooves the residential provider to establish
  a close relationship with its local DHS office.

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Fee for Service Billing Target

• Based on the survey data and the medical
  necessity of the average ICG client, we conclude
  that 40 of the Illinois Purchase of Care Review
  Board rate is an appropriate target for FY2009.
• Average ICG client is high need and thus
  requires medically necessary residential
  services.
• The ICG program is committed to working with
  providers to assist them in optimal billing for
  medically necessary services.

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Enhanced Clinical Care Management

• Collaborative Clinical Care Managers will play a
  supportive role for families and SASS-ICG
  providers.
• DMH intends to use the services of clinical are
  managers in increasingly significant roles.
• The specifics of enhanced clinical care manager
  role will be provided in a future webinar.

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One-to- One Staffing

• DMH will no longer reimburse providers to
  one-to-one staffing.
• DMH expects this service will be available when
  clinically necessary and included in the costs
  submitted to the Illinois Purchase Care Review
  Board.

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Family Income Requirement

• ICG applicants must indicate their family income
  and submit copies of federal income tax returns.
• The family income requirement is a requirement
  for other DHM programs. This addition to the ICG
  application brings ICG into alignment with other
  DMH program.

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Unusual Incident Reports

• UIRs are reserved for truly unusual incidents.
  Verbal aggression and property destruction are
  not considered unusual for the ICG population and
  thus UIRs are not required.
• Any sentinel event must be immediately reported
  to ICG via phone with follow-up paper work within
  24 hours.
• Other incidents (e.g. severe aggression,
  self-injurious behavior resulting in medical
  attention in a hospital or clinic, elopement,
  behavior involving police intervention, etc.
  shall be reported within 2 business days.

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Unusual Incident Reports

• Not all elopements need to be reported.
  Elopements that involve the client leaving the
  property of the facility for more than an hour
  and out of the control of staff shall result in a
  UIR.
• UIRs should be sent to Chumiach Houston at 4200
  N. Oak Park Avenue/Annex, Chicago, IL.

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Annual Eligibility Reviews

• Annual Reviews are now being referenced as Annual
  Eligibility Reviews to emphasize the fact that
  the outcome and an AR is an eligibility decision.
  
• Funding will be terminated when ICG clients who
  no longer meet the clinical criteria for the
  program.
• The Ohio Scales and the Columbia Impairment Scale
  are to be included in the Annual Eligibility
  Report.

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Quarterly Reports

• Quarterly Reports are required for all ICG
  clients.
• A quarter is defined as 90 days from the date of
  grant anniversary.
• Include Ohio Scales and Columbia Impairment Scale
  information in the Quarterly Report.

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Quarterly Reports

• Quarterly Reports shall answer the 10 items
  contained in the Quarterly Report Questionnaire
• Briefly describe the reason for admission.
• Describe the treatment goals you hope to
  accomplished.
• Describe the current efforts you are making to
  prepare the client for discharge. Give a
  tentative discharge date.
• List the discharge criteria that need to be met
  before discharge can occur.
• List current diagnoses. Include CGAS, Ohio
  Scales, and Columbia Impairment Scale.

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Quarterly Reports

• Progress of psychotherapy and number of sessions
  per week .
• Progress in family therapy and number of sessions
  per month.
• Progress in any specialized therapy, if
  appropriate.
• Family involvement in the clients treatment.
• Anything else considered relevant to the clients
  treatment.

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UPDATING RESIDENTIAL INFORMATION

• Information regarding residential services
  frequently changes.
• SASS-ICG providers will submit a monthly list of
  residential clients on their case loads to the
  Collaborative.
• Updated lists will help keep the Collaborative
  current regarding changes in placements.

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APPENDIX

• For detailed description of all Rule 132
  services, go to http//www.hfs.illinois.gov/asse
  ts/070107_cmph_guide.pdf for the State of
  Illinois Community Mental Health Services Service
  Definition and Reimbursement Guide
• The appendix provides service definitions,
  examples, and minimal credentials for providing
  services from the reimbursemet guide.

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Service Definitions

• CASE MANAGEMENT - CLIENT-CENTERED CONSULTATION
  An individual client-focused professional
  communication between provider staff, or staff of
  other agencies, or with other professionals or
  systems who are involved with providing services
  to the client.
• Examples Face-to-face contacts, staffing with
  school personnel, contacts with legal or medical
  system
• Minimum staff requirement - RSA

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Service Definitions

• CASE MANAGEMENT - MENTAL HEALTH Services include
  assessment, planning, coordination, and advocacy
  services for clients who need multiple services
  and require assistance in gaining access to and
  in using mental health, social, vocational,
  educational, housing, public income entitlements
  and other community services to assist the client
  in the community. Case management activities may
  also include identifying and investigating
  available resources, explaining options to the
  client and linking them with necessary resources.

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Service Definitions

• CASE MANAGEMENT - MENTAL HEALTH EXAMPLES
• Helping the client access appropriate mental
  health services, including the ICG program, apply
  for public entitlements, locate housing, obtain
  medical or dental care or obtain other social,
  educational, vocational, or recreational
  services.
• Assessing the need for service, identifying and
  investigating available resources, explaining
  options to the client and assisting in the
  application process.

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Service Definitions

• CASE MANAGEMENT - MENTAL HEALTH minimum staff
  requirement - RSA

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Service Definitions

• CASE MANAGEMENT - TRANSITION LINKAGE AND
  AFTERCARE Services are provided to assist in an
  effective transition in living arrangement
  consistent with the clients welfare and
  development.

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Fee for Service and Treatment

• The lack of intensity of services, particularly
  in regard to individual, group, and family
  therapy may explain ICGs average length of stay
  as 2.5 years.
• Research indicates that after two years of
  residential placement, it is unlikely that the
  client will return to home and the community.

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Service Definitions

• CASE MANAGEMENT - TRANSITION LINKAGE AND
  AFTERCARE Examples
• Services to clients being discharged inpatient
  psychiatric care, transitioning to adult
  services
• time spent planning with the staff of the
  clients current living arrangement or the
  receiving living arrangement
• Time locating client-specific placement
  resources
• Time spent developing aftercare service plan
• Assisting the client or the clients family or
  caregiver with the transition.

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Service Definitions

• CASE MANAGEMENT - TRANSITION LINKAGE AND
  AFTERCARE minimum staff requirement - MHP

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Service Definitions

• COMMUNITY SUPPORT RESIDENTIAL (INDIVIDUAL,
  GROUP) Services and support for children,
  adolescents, adults, and families necessary to
  assist a client to achieve and maintain
  rehabilitative, resiliency, and recovery goals.
  The service consists of therapeutic interventions
  that facilitate illness self-management, skill
  building, identification and use of natural
  supports , and use of community resources.

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Service Definitions

• COMMUNITY SUPPORT (RESIDENTIAL) EXAMPLES
• Coordination and assistance with the
  identification of individual strengths,
  resources, preferences, and choices.
• Assistance with the identification of existing
  natural supports for the development of a natural
  support team.
• Assistance with the development of crisis
  management plans.

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Service Definitions

• Skill building in order to assist the client in
  the development of functional, interpersonal,
  family, coping and community living skills that
  are negatively impacted by the clients mental
  illness.
• Assistance with risk factors related to relapse
  prevention and prevention plans.
• Support and promotion of client self-advocacy and
  participation in decision-making, treatment, and
  treatment planning

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Service Definitions

• COMMUNITY SUPPORT (RESIDENTIAL) minimum staff
  requirement - RSA

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Service Definitions

• CRISIS INTERVENTION Activities or services
  provided to a person who is experiencing a
  psychiatric crisis that are designed to interrupt
  the crisis experience including assessment, brief
  supportive therapy or counseling and referral
  and linkage to appropriate community services to
  avoid more restrictive levels of treatment, with
  the goal being symptom reduction, stabilizing and
  restoration to a previous level of functioning

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Service Definitions

• CRISIS INTERVENTION EXAMPLES
• All activities must occur within the context of a
  potential psychiatric crisis.
• Face-to-face or telephone contact with the client
  for the purpose of preliminary assessment of need
  for mental health services.
• Face-to-face or telephone contact to provide
  immediate, short-term, crisis-specific therapy or
  counseling with client, and, as necessary, with
  clients caretaker or family.
• Referral to other applicable mental health
  services. Including pre-hospitalization
  screening.
• Face-to-face consultation with a physician or
  hospital staff regarding need for psychiatric
  consultation.

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Service Definitions

• CRISIS INTERVENTION minimal staff requirement -
  MHP with immediate access to a QMHP.

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Service Definitions

• JOB FINDING Activities for a specific client,
  directed toward helping them find a and procure a
  job, when provided under the following
  conditions placement based on consumer job
  preferences, competitive employment in integrated
  work settings, on-going supports as needed and
  integration of supported employment services with
  other mental health services.

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Service Definitions

• JOB FINDING EXAMPLES
• Helping the client identify job leads.
• Reviewing the clients network of job leads.
• Contacting employers about a job for a specific
  client.
• Assisting a client in completing employment
  applications.
• Arranging a job interview
• Evaluating a job site to determine if it is a
  good fit for the client.
• Facilitating a group where clients exchange job
  leads and their experience using various
  job-finding strategies with one another.

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Service Definitions

• JOB FINDING minimum staff requirement - RSA.

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Service Definitions

• JOB RETENTION SUPPORTS Activities for a specific
  client directed toward helping them keep their
  job, when provided under the following
  conditions placement based on consumer job
  preferences, competitive employment in integrated
  work settings, on-going supports as needed and
  integration of supported employment services with
  other mental health services.

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Service Definitions

• JOB RETENTION SUPPORTS EXAMPLES
• Helping the client identify and make use of their
  support system to manage their concerns about
  work.
• Frequently talking with client about changes in
  health, work environment, or personal environment
  to identify needed support categories.
• Helping the client identify and implement
  strategies that improve job performance or
  relationships at work.

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Service Definitions

• JOB RETENTION SUPPORTS minimum staff requirement
  - RSA.

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Service Definitions

• JOB LEAVING/TERMINATION SUPPORTS Activities for
  a specific client, who is employed, directed
  toward helping them leave a job in good standing,
  when provided under the following conditions
  placement based on consumer job preferences,
  competitive employment in integrated work
  settings, on-going supports as needed and
  integration of supported employment services with
  other mental health services. Job
  Leaving/Termination Supports may also be provided
  to help the client see unplanned job loss as a
  transitional and a learning experience that will
  help them with their next job. Job
  Leaving/Termination Supports are provided to
  ensure that a job loss due to termination is not
  seen as a reason to discontinue participation in
  the supported employment program.

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Service Definitions

• JOB LEAVING/TERMINATION SUPPORTS EXAMPLES
• Using motivational interviewing to help client
  identify the pros and cons of leaving their job.
• Deciding how much notice is required to leave in
  good standing.
• Coaching on talking to a supervisor about
  resigning.
• Helping write a letter of resignation.
• Coaching on how to obtain a letter of reference.

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Service Definitions

• JOB LEAVING/TERMINATION SUPPORTS minimal staffing
  requirement - RSA.

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Service Definitions

• ORAL INTERPRETATION AND SIGN LANGUAGE Sign
  language/oral interpreter services necessary to
  ensure the provision of services for individuals
  with hearing impairments or in the primary
  language of non-English speaking individuals.
  Interpreters shall be linguistically appropriate
  in English and in the primary language of the
  individual and be able to translate critical
  information effectively.

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Service Definitions

• ORAL INTERPRETATION AND SIGN LANGUAGE minimal
  staff requirement - specialist.

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Service Definitions

• MENTAL HEALTH ASSESSMENT The formal process of
  gathering into written reports information on the
  client - including, but not limited to,
  individual characteristics, presenting problems,
  history or cause of illness, history of
  treatment, psychosocial history and current
  functioning in emotional, cognitive, and behavior
  domains through face-to-face or personal contact
  with client or collaterals. The service results
  in identification of the clients mental health
  service needs and recommendations for treatment
  and may include a tentative diagnosis.

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Service Definitions

• MENTAL HEALTH ASSESSMENT EXAMPLES
• Face-to-face meeting with the client in order to
  assess the clients needs.
• Face-to-face meeting or telephone contact with
  the client or clients family to collect social
  history information.
• Administering CGAS/GAF or other acceptable
  instruments to the client to document substantial
  impairment in role functioning.
• Annual update of the assessment

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Service Definitions

• MENTAL HEALTH ASSESSMENT minimal staff
  requirement - MHP under the direct supervision of
  a QMHP. QMHP and LPHA must sign the mental health
  assessment report and annual update.

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Service Definitions

• PSYCHOLOGICAL EVALUATION A psychological
  evaluation conducted and documented by the
  provider consistent with the Psychologist
  Licensing Act (225 ILCS 15), using nationally
  standardized psychological assessment instruments.

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Service Definitions

• PSYCHOLOGICAL EVALUATION EXAMPLES
• Client interview or clinical observation.
  Interview with parent or guardian, if indicated.
• Administration of nationally recognized
  psychological assessment instruments as part of a
  psychological evaluation.

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Service Definitions

• PSYCHOLOGICAL EVALUATION minimum staff
  requirement - The evaluation must be conducted
  and signed by a licensed clinical psychologist.

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Service Definitions

• PSYCHOTROPIC MEDICATION ADMINISTRATION Time
  spent preparing the client and the medication for
  administration, administering psychotropic meds,
  observing the client or possible adverse
  reactions, and returning medications to proper
  storage.

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Service Definitions

• PSYCHOTROPIC MEDICATION ADMINISTRATION EXAMPLE
  In addition to the activities in the service
  definition, drawing blood per established
  protocol for a particular psychotropic medication.

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Service Definitions

• PSYCHOTROPIC MEDICATION ADMINISTRATION minimum
  staff requirement - LPN under RN supervision.

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Service Definitions

• PSYCHOTROPIC MEDICATION MONITORING Monitoring
  and evaluating target symptom response, adverse
  effects include tardive dyskinesia screens, and
  new target symptoms or medication.

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Service Definitions

• PSYCHOTROPIC MEDICATION MONITORING EXAMPLES
• Face-to-face interview with clients reviewing
  response to psychotropic medications.
• Medication monitoring may include clinical
  communication by phone or face-to-face between
  staff of the (same) provider agency, under
  situations which constitute an appropriate
  release of information, emergency medical, life
  safety intervention, or consulting therapist
  relationships regarding the clients psychotropic
  medication.
• Review laboratory results with clients that are
  related to the clients psychotropic medication.

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Service Definitions

• PSYCHOTROPIC MEDICATION MONITORING minimum staff
  requirement - Staff designated in writing by a
  physician or advanced practice nurse per a
  collaborative agreement.

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Service Definitions

• PSYCHOTROPIC MEDICATION TRAINING Includes
  training the client or the clients family or
  guardian to administer the clients medication,
  to monitor proper levels and dosage, and to watch
  for side effects.

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Service Definitions

• PSYCHOTROPIC MEDICATION TRAINING EXAMPLES When
  indicated based on clients condition and
  included in the ITP, face-to-face meetings with
  individuals clients to discuss the following
• Purpose of taking the medications.
• Psychotropic medications, effects, side effects,
  and adverse reactions.
• Self-administration of medications.
• Storage and safeguarding of medications.
• How to communicate with MH professionals
  regarding medication issues.
• How to communicate with family/caregivers
  regarding medication issues.

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Service Definitions

• PSYCHOTROPIC MEDICATION TRAINING minimum staff
  requirement - staff designated in writing by a
  physician or advanced practice nurse per a
  collaborative agreement.

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Service Definitions

• THERAPY/COUNSELING Treatment to provide
  emotional, cognitive, behavioral or psychological
  changes using psychotherapy theory and techniques.

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Service Definitions

• THERAPY/COUNSELING EXAMPLES
• Formal face-to-face or videoconference meetings
  or telephone contacts with the client or clients
  family as specified in the ITP.
• Conducting form face-to-face group psychotherapy
  sessions with the client or his/her family,
  addressing a specific problem such as low
  self-esteem, poor impulse control, depression,
  etc.
• CBT, Functional Family Therapy, Motivation
  Enhancement Therapy, Trauma Counseling, Anger
  Management, Sexual Offender Treatment.

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Service Definitions

• THERAPY/COUNSELING minimum staff requirement -
  MHP. ICG staff requirement - QMHP

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Service Definitions

• TREATMENT PLANNING The development of a plan, in
  conjunction with the client and parent/guardian
  as applicable, to deliver specific mental health
  services to a client, base on the service needs
  identified in the mental health assessment, which
  includes goals, objectives, specific mental
  health services, frequency and identification of
  staff responsible for delivering these services.
  The LPHA and QMHP shall review the ITP no less
  frequently than every six months and make any
  modification if necessary.

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Service Definitions

• TREATMENT PLANNING EXAMPLES
• Meeting with the client or parent/guardian to
  discuss, develop, or review treatment plan.
• Face-to-face meetings with family members,
  collaterals or other persons essential to the
  development or review of the treatment plan, with
  clients permission.
• Treatment team meetings used for ITP development
  and/or formalized review of the effectiveness of
  the entire plan. LPHA or QMHP must be present.
• Time spent y the QMHP/MHP reviewing the
  assessment materials and developing ITP with
  others (but not time spent writing/typing the
  document).

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Service Definitions

• VOCATIONAL ENGAGEMENT Activities for a specific
  client to engage the client in making a decision
  to actively seek competitive employment or formal
  credit/certificate bearing education.

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Service Definitions

• VOCATIONAL ENGAGEMENT EXAMPLES
• Using motivational interviewing to assist client
  in identifying pros and cons of working.
• Educating the family on the benefits of
  employment to the client.
• Leading groups that explore concerns raise by
  clients considering employment.
• Going to job sites with the client to explore
  that world of work.

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Service Definitions

• VOCATIONAL ASSESSMENT Developing a vocational
  profile to guide client choices in seeking and
  maintaining competitive employment. A vocational
  profile typically includes information pertaining
  to work history, interests, skills, strengths,
  education, the impact of symptoms on the ability
  to use strengths, job preferences, etc.
  Vocational assessment is continuous during all
  phases of obtaining and maintaining employment.
  New information from experience is incorporated
  to guide modification of the vocational plan.

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Service Definitions

• VOCATIONAL ASSESSMENT EXAMPLES
• Using interest and preference inventories to
  increase clients personal knowledge of
  employment-related interests and preference.
• Administering a test to determine basic reading
  and math abilities.
• Visiting competitive work sites with client.
• Gathering information that an employer might find
  on background check.

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Questions or Concerns

• Seth.harkins_at_illinois.gov
• William.white_at_valueoptions.com