Transcript Crisis_Redesign_Overview_Training_10-22-07

Crisis Services Redesign
Implementation Overview for LMHA’s
Presenter: Mike Maples, Director MHSA
Overview
In December 2005, then Commissioner of
Texas Department of State Health Services
(DSHS), Eduardo Sanchez established the
Crisis Services Redesign Committee to
develop recommendations for mental health
and substance abuses crisis services that are
delivered throughout the local mental health
authorities in the State of Texas.
Purpose of Redesign
The charge to the Crisis Redesign Committee
and the purpose of redesign was to develop
recommendations for a comprehensive array
of specific services that will best meet the
needs of Texans who are having a mental
health and/or substance abuse crisis.
Goals of Crisis Redesign
A consistent state of the art system of crisis
services across Texas with improved:

Accessibility

Standards of care

Community involvement

Consumer choice

Less restrictive treatment environments

Lessening burden on hospitals, jails & law
enforcement
Crisis Services Redesign
Committee
This committee was formed with representation from:





NAMI
Advocacy Groups
State and Private Hospitals
Mental Health professionals
Mental support groups and
prevention groups




Physicians
Law Enforcement and
Judiciary
DSHS
Community Mental Health
Centers
The recommendations from this group are guiding
the course for Crisis Redesign now in it’s
Implementation Phase.
Crisis Services Funding


REQUESTED: DSHS requested $82 million from
the 80th Legislature to make significant progress
toward improving the response to behavioral
health crises.
AWARDED: Through the Legislature and Rider
69, the full $82 million was granted over fiscal
years 2008/ 2009 to redesign and improve the
mental health crisis system across Texas.
Crisis Services Funding, cont.

$27.3 million will be allocated in FY 08

$54.7 million will be allocated in FY 09

Additional funds will be requested from the 81st
Legislature

It is required that new crisis redesign general
revenue funds will be used to improve crisis
services provided and not replace the current
crisis services.
Allocation of Funds

Consistent with the proposed use of funds
described in the Legislative Appropriation
Request (LAR), the new crisis funds will be
divided into five portions:





EQUITY
PROPORTIONAL
COMMUNITY INVESTMENT INCENTIVE
COMPETENCY RESTORATION ALLOCATION
STATE EXPENDITURES
Equity


To address inequities that have developed
over time among funding for LMHA’s
Allocates 32% (approximately $27million) to
bring under-funded LMHAs up to the current
state average of per capita funding
Proportional

Allocates 36% (almost $30 million) to be divided
proportionally. However under this simple per
capita distribution, many Centers would not
receive sufficient dollars to allow full
implementation of initial services. Thus DSHS
will first assure that all Centers receive enough
funding to for Crisis Hotline and Mobile Crisis
Outreach Teams (MCOTs) and then will divide
the remaining funds on a per capita basis.
Community Incentive

Additionally, there will be community investment
incentive funds which will allow LMHAs
(including NorthStar) or groups of LMHAs who
provide 25% local match to compete for extra
dollars to create the following:


Psychiatric Emergency Service Centers (PESCs)
Projects for jail diversion or alternatives to State
hospitalization
Competency Restoration Funds


$3 Million over the FY08-09 biennium will be
available to LMHAs including NorthStar
LMHAs and NorthStar may apply for these
additional funds to provide outpatient
competency restoration services to individuals
who are incompetent to stand trial but are
eligible to receive mental health outpatient
treatment
State Expenditures

1.5% or about 1.2 million will be used by
DSHS to support the crisis redesign initiative
over the biennium including:



Hotline training by AAS (American Association of
Suicidology)
Four DSHS staff positions
An independent evaluation of the project at a later
date
Crisis Services Standards
Presenter: Jennifer Edwards, DSHS
Community MHSA Program Services Section
Crisis Services Standards
DSHS has promulgated Standards for all
services in the crisis service array. Standards
address:
Description of service
 What acuity is served in each service
 Plant/facility requirements
 Staff credentials and training requirements
 Assessment parameters
 Services provided and time frames for delivery
 Continuity of care

Initial Crisis Services: Hotline

Every LMHA will be required to provide a continuously
available telephone hotline staffed by trained hotline
workers who provide information, screening and
assessment, intervention and support to callers 24
hours per day, 7 days per week.
What’s new about hotline?

Hotlines must be accredited by the American
Association of Suicidology (AAS)

Thorough training and adherence to standards will
ensure consistency
Crisis Hotline Training


The American Association of Suicidology (AAS)
was selected by DSHS as the accrediting body
for hotlines across the state. Their curriculum
involves extensive training and demonstration
of competency.
Two key training objectives:


Immediate access to quality hotline training
Development of a sustainable training infrastructure
Crisis Hotline Training, cont.

DSHS will host four regional AAS hotline
training events in FY 08:





Dallas
Houston
Austin
Corpus Christi
Two tracks will be provided—three days for
hotline workers and two additional days for
Train-the-Trainer
Crisis Hotline Training, cont.


Trainers completing the Train-the-Trainer
course may train other hotline workers for the
future
Additional DSHS staff will become certified
trainers and will be available to provide future
training
Initial Crisis Services:
Mobile Crisis Outreach Teams
Mobile Crisis Outreach Teams provide a
combination of crisis services including
emergency care, urgent care, and crisis followup and relapse prevention to the child,
adolescent, or adult in the community.
Mobile Crisis Outreach
What’s new about
Mobile Outreach?


Greater accessibility to Mobile Crisis Outreach
Teams (MCOTs)
Specific MCOT Standards regarding delivery of
services and training & experience required of
MCOT Staff
Mobile Crisis Outreach Teams





Staffing Patterns: Availability 24/7 in all communities
Urban LMHAs: Minimum of one MCOT on duty during
LMHA-designated “peak hours” totaling 84 hours per
week
One additional Urban MCOT on call 24/7
Rural LMHAs: One MCOT on duty during LMHAdesignated “peak hours” totaling 56 hours per week
MCOT capability is maintained throughout the Local
Service Area (LSA) 24/7
Mobile Crisis Outreach Teams



Not every county in the LSA needs an MCOT; however
the ability to meet face-to-face within one hour remains
a Community Standard
Team Composition: A MCOT, at a minimum, is
comprised of 2 QMHP-CSs or where appropriate, 1
QMHP-CS and law enforcement
Urban LMHAs: QMHP-CS is deployed with an RN,
LPHA, or physician, preferably a psychiatrist, on every
emergent care call
Mobile Crisis Outreach Teams



Rural LMHAs: It is recommended that a QMHP-CS is
deployed with an RN, LPHA, or physician, preferably a
psychiatrist. If not deployed as part of the MCOT, a
physician, LPHA, or RN must be available to provide
face-to-face assessment as needed or clinically
indicated.
Location: MCOT services are designed to reach
individuals in their place of residence, school, and/or
other community-based safe locations
Services Provided: Crisis assessment, crisis
intervention services, and crisis follow-up and relapse
prevention
Roll-out of Crisis Redesign
Initial Services to be Implemented:
 Hotline
 Mobile
Crisis Outreach Team
These are the initial services expected for
implementation and adherence to standards.
Any remaining funds post-implementation of
hotline and MCOT will be available to LMHAs to
spend on “Enhanced Services”
Enhanced Services

Crisis Outpatient Services

Extended Observation Services (up to 48 hours)

Crisis Stabilization Units (CSUs)

Crisis Residential (Child or Adult)

Crisis Respite (Child or Adult)

Mental Health Deputies/Crisis Intervention Teams

Transportation

Purchase of additional inpatient hospital beds
Enhanced Crisis Services
Crisis Outpatient Services:
Office-based outpatient services for adults, children and
adolescents providing immediate screening and
assessment and brief, intensive interventions focused on
resolving a crisis and preventing admission to a more
intensive level of care
Staffing Requirements:
All crisis services staff are trained physicians, preferably
psychiatrists, RNs, LPHAs, QMHP-CSs, or
Paraprofessionals (Behavioral Health Technicians)
Crisis Outpatient Services

Screening and Assessment Timeframes:



Location:


Face to Face triage or screening by QMHP-CS within
15 minutes of presentation
LPHA or RN completes crisis assessment within 1
hour of referral from the screening process
Crisis Outpatient Services are office-based outpatient
services
Community Mental Health Centers (CMHCs)
may provide extended hours or time on
weekends to deliver walk-in crisis services
Crisis Outpatient Services

Continuity of Care:
Upon resolution of the crisis, every eligible
individual shall be transitioned into Service
Packages 1-4 if determined to be medically
necessary, or receives Crisis Follow-Up (SP5)
throughout a 30-day period until he/she is
stabilized and/or transitioned to appropriate
behavioral health services.
Extended Observation Services

Extended Observation Services:
Emergency and crisis stabilization services are
provided to individuals in a secure and
protected, clinically staffed (including medical
and nursing professionals), psychiatrically
supervised treatment environment with
immediate access to urgent or emergent
medical evaluation and treatment. Individuals
who cannot be stabilized within 48 hours would
be linked to the appropriate level of care
(inpatient hospital unit or CSU).
Extended Observation Services
Staffing Requirements:
Physicians, (preferably psychiatrists) RNs (APNs),
LPHAs, QMHPs (PAs), and Paraprofessionals
(Behavioral Health Technicians)
 Screening and Assessment Timeframes:
Triage by RN or Physician within 15 minutes of
presentation
 Individuals who are not referred for care
elsewhere after triage receive a full assessment
(psychosocial, psychiatric and as ordered
medical) initiated within one hour of the
individual’s presentation to the extended
observation services

Extended Observation Services

Screening and Assessment Timeframes, cont.:
Staffing patterns should allow individual
reassessment at least every 15 minutes for
behavioral health technicians, two hours for nursing,
four hours for QMHPs, and 12 hours for physicians,
preferably psychiatrists
Extended Observation Services

Continued care Staffing:
 A physician preferably a psychiatrist on call 24
hours/day to evaluate individuals face to face or
via telemedicine as needed;
 At least one LPHA on site 24 hours/day, seven
days/week;
 At least one RN on site 24 hours/day, seven
days/week; and
 Behavioral health technician(s) on site 24
hours/day, seven days/week
Extended Observation Services


Location:
Secure location with immediate access to urgent or
emergent medical evaluation and treatment
If services are provided for children and
adolescents, the physical plant must have separate
child, adolescent, and adult observation areas.
Extended Observation Services

Coordination of Care:
Consists of identifying and linking the individual with
all available services necessary to stabilize the
crisis and ensure transition to routine care,
providing necessary assistance in accessing those
services, and conducting follow-up to determine the
individual’s status and need for further service.
This includes contacting and coordinating with the
individual’s existing services providers in a timely
manner and in conformance with applicable
confidentiality requirements.
Crisis Stabilization Units (CSU)

Short-term residential treatment designed to
reduce acute symptoms of mental illness
provided in a secure and protected clinically
staffed, psychiatrically supervised, treatment
environment that complies with a crisis
stabilization unit licensed under Chapter 577 of
the Texas Health and Safety Code and Title 25,
Part 1, Chapter 411, Subchapter M of the
Texas Administrative Code.
Crisis Residential
Child and Adult:

Provide short-term, community-based residential, crisis
treatment to persons with some risk of harm who may
have fairly severe functional impairment. These
facilities provide a safe environment with clinical staff
on site at all times however they are not designed to
prevent elopement and individuals must have at least a
minimal level of engagement to be served in this
environment. The recommended length of stay is from
1-14 days.
Crisis Residential

Staffing Patterns:
There is an on-call roster of clinical (QMHP-CS and
above) and nursing (RN and LVN) staff. There is a
process for assessing and anticipating staffing needs to
ensure clinical or nursing staff are on-site at all times.
Behavioral health technicians and nursing staff may
used on the overnight shift.
Crisis Residential

Screening and Assessment Timeframes:
Prior to admission to the Crisis Residential Unit
individuals receive a full psychiatric assessment within
24 hours of the individual’s presentation to the service if
not referred directly from an active inpatient unit or
psychiatric emergency service.
Crisis Residential

Screening and Assessment Timeframes, cont.:
Individuals, not currently in services or for whom the
health status is unknown, receive a comprehensive
nursing assessment by an RN within 1 hour of
presentation
 If ordered, individuals receive a physical health
assessment by an RN, within two hours of entering
a crisis residential unit unless already conducted
within the last week. This evaluation includes
assessment of medical and psychiatric stability, selfadministration of medication capability, vital signs,
pain, and danger to self or others.
Crisis Residential

Treatment Interventions:
An array of treatment interventions may exist in the
crisis residential setting and may include individual or
group psychotherapy or psychoeducation, crisis
intervention and crisis psychotherapy, family therapy,
advocacy, help with obtaining community supports
and housing, help developing social skills and a social
support network, substance abuse treatment, and
relapse prevention. A minimum of 4 hours per day of
such programming should be provided. Individuals
who have significant substance abuse comorbidity
receive counseling designed to motivate the patient to
continue with substance abuse treatment following
discharge from the program.
Crisis Residential

Location:
Crisis residential services units provide a safe
environment; however they are not designed to prevent
elopement. They are to provide as normalized of an
environment as possible, with 16 beds or less. All
medications are securely stored.
Crisis Residential

Coordination of Care:
Coordination of emergency services is provided for
every individual. Coordination of emergency services
consists of identifying and linking the individual with all
available services necessary to stabilize the crisis and
ensure transition to routine care, providing necessary
assistance in accessing those services, and
conducting follow-up to determine the individual’s
status and need for further service.
Crisis Respite
Child and Adult:





Provide short-term, community-based residential, crisis
treatment
Individuals in a crisis respite have no risk of harm to self
or others and may have some functional impairment
and require direct supervision and care but do not
require hospitalization
Generally serves individuals with housing challenges or
assist caretakers who need short-term housing for the
persons for whom they care to avoid a mental health
crisis.
Utilization of these services is managed by the LMHA
based on medical necessity.
The recommended length of stay is 1-7 days.
Crisis Respite
Child and Adult:

Staffing Patterns: There is a defined process for on-site
staff to obtain supervision, consultation, and evaluation
when needed and for medical and psychiatric
emergencies 24 hours a day from a physician,
preferably a psychiatrist, APN, or PA.
 Mental health aide(s)/behavioral health technician(s)
are on site 24 hours a day, with numbers,
qualifications, and training sufficient to ensure
patient and staff safety and the provision of needed
services.
 Staff members providing in-home crisis respite
services to children or adolescents are Qualified
Mental Health Professionals competent to provide
crisis services to children and adolescents.
Crisis Respite
Child and Adult:


Screening and Assessment Timeframes: Prior to
admission to Crisis Respite Services, individuals
receive a full crisis assessment by a physician,
preferably a psychiatrist, LPHA, RN or other Qualified
Mental Health Professional.
Treatment Interventions: Individual and group skills
training are provided at the crisis respite site and are
based on the needs of the individual and the goals of
their individual crisis plans.
 A stable therapeutic environment exists in facilitybased crisis respite units that includes assigned
personnel and scheduled activities.
Crisis Respite
Child and Adult:

Location: Contracted assisted living facilities used for
crisis respite units are subject to licensing regulations of
the Department of Aging and Disability Services
(DADS) as Assisted Living Facilities.
 These services can occur in houses, apartments, or
other community living situations
Crisis Respite
Child and Adult:
 Coordination of Care: Coordination of emergency
services is provided for every individual. Coordination
of emergency services consists of identifying and
linking the individual with all available services
necessary to stabilize the crisis and ensure transition to
routine care, providing necessary assistance in
accessing those services, and conducting follow-up to
determine the individual’s status and need for further
service.
Psychiatric Emergency Service
Centers (PESCs)




Available as part of Community Investment Incentive
Funding
Provide immediate access to assessment and a
continuum of stabilizing treatment for individuals
presenting with behavioral crises.
These units are co-located with licensed hospitals or
Crisis Stabilization Units (CSUs) and have the ability to
manage the most severely ill individuals at all times,
including immediate access to emergency medical
care.
PESCs must be available to individuals who walk in,
and contain a combination of service types including
Extended Observation and Inpatient Hospital Services
or a CSU.
Psychiatric Emergency Service
Centers (PESCs)

Staffing Patterns: A physician, preferably a
psychiatrist on call 24 hours/day to evaluate individuals
face to face or via telemedicine as needed;
 At least one LPHA on site 24 hours/day, seven
days/week;
 At least one RN on site 24 hours/day, seven
days/week; and
 Behavioral health technician(s) on site 24 hours/day,
seven days/week.
Psychiatric Emergency Service
Centers (PESCs)

Screening and Assessment Timeframes:
Individuals who are not referred for care elsewhere
after triage receive a full assessment that is initiated
within one hour of the individual’s presentation.
 Individuals who receive an assessment see a
psychiatrist within eight hours of presentation to the
PESC.
 The unit has sufficient staff to allow for individual
reassessment at least every 15 minutes for
behavioral health technicians, two hours for nursing,
four hours for QMHPs, and 12 for physicians,
preferably psychiatrists.
Psychiatric Emergency Service
Centers (PESCs)

Treatment Interventions: Treatment planning
places emphasis on crisis intervention services
necessary to stabilize and restore the individual to a
level of functioning that does not require hospitalization.
 An LPHA is responsible for providing the individual
with active treatment including psychoeducation,
crisis counseling, substance abuse counseling, and
developing a plan for returning to the community that
addresses potential obstacles to a successful return.
Psychiatric Emergency Service
Centers (PESCs)

Location: Services are co-located with a DSHS
licensed hospital or CSU.



The LMHA must have a written agreement with the
hospital or CSU with which the PESC is co-located.
Facilities are accessible and meet all Texas
Accessibility Standards.
Facilities have provisions for ensuring safety.
Psychiatric Emergency Service
Centers (PESCs)

Location, cont.:



Offices have at least one designated area where
persons in extreme crisis can be safely maintained
until transported to another level of care (e.g.,
hospital or crisis stabilization unit).
Facility spaces afford privacy for protection of
confidentiality.
If services are provided for children and adolescents,
the facility must have separate child, adolescent,
and adult treatment and observation areas.
Psychiatric Emergency Service
Centers (PESCs)

Coordination of Care: Coordination of care consists
of identifying and linking the individual with all available
services necessary to stabilize the crisis and ensure
transition to routine care, providing necessary
assistance in accessing those services, and conducting
follow-up to determine the individual’s status and need
for further service. This includes contacting and
coordinating with the individual’s existing services
providers in a timely manner and in conformance with
applicable confidentiality requirements.
Local Crisis Service Plans
Presenters: Chris Dickinson and
Dorcas Washburn
Community MHSA Program Services Section
Local Crisis Planning
LMHAs shall develop, update and maintain a
Crisis Service Plan designed to meet the needs
and priorities of the community and to meet the
following objectives





Rapid response
Local stabilization when possible
Diversion from incarceration
Reduced burden on law enforcement
Decreased utilization of emergency healthcare
resources
Local Crisis Planning
Community
stakeholders are a
vital part of the local
planning process and
will be key in
successful
implementation of
crisis services.
Local Crisis Planning
Community Stakeholders Involved:







Client representatives
Client family member
representatives
Child and adult advocates
Mental health service
providers
Emergency healthcare
providers
Local public healthcare
providers
Law enforcement





Probation and parole
department staff
Judicial representatives from
each county
Outreach, Screening,
Assessment and Referral
(OSAR) provider(s)
Substance abuse service
providers
Others deemed appropriate
by the LMHA (such as
concerned citizens, private
sector)
Local Crisis Planning
 The
Crisis Service Plan shall include a
description of the collaborative process and
efforts
(include ongoing efforts to engage
stakeholders who are not involved)
Local Crisis Planning
Crisis Service Plans shall include a description of
the current service gaps or community needs
related to the delivery of crisis services for adults,
adolescents and children, as well as gaps related
to the delivery of crisis services to individuals with
co-occurring psychiatric and substance use
disorders.
Local Crisis Planning
Crisis Service Plans shall include a description of
how the new crisis funding will be used to
improve first Contractor’s Hotline and Mobile
Crisis Outreach Team infrastructure, training, and
crisis response processes to achieve American
Association of Suicidology accreditation and
meet DSHS promulgated standards
Local Crisis Planning

The Crisis Service Plan shall include a
description of existing crisis response system to
include:
 Type
and quantity of crisis services provided
 Flowchart describing crisis response system
 Staff make-up
 Training requirements
 Budget

How funds will be applied to meet Hotline and
MCOT standards
Local Crisis Planning

How remaining new crisis funding will be used for
enhancement or to implement the following services and
bring into compliance with new standards:








Crisis Outpatient Services (Children or Adult)
Extended Observation
Crisis Stabilization Unit
Crisis Residential (Children or Adult)
Crisis Respite (Children or Adult)
Psychiatric Emergency Service Centers
Crisis Intervention Team (CIT)/Mental Health Deputies
Program
Crisis Transportation
CRISISLocal
PLANNING
Crisis
Planning
The Crisis Service Plan shall include:




A description of how the LMHA will coordinate
with other local crisis response systems
How services provided will improve or develop the
local crisis response system’s ability to divert
individuals from incarceration, or find alternatives to
psychiatric hospitalization.
Any written agreements between crisis response
entities and any marketing/public relations efforts to
inform the community about the changes in the crisis
response system.
A description of strategies that will maximize the
funding available to provide crisis services, including
any collaboration with local or regional stakeholders
LBB & Contract Performance
Presenters: Chris Dickinson and
Karen Ruggiero
Community MHSA Program Services Section
LBB and Contract Performance
Measuring Accountability

DSHS must report to the Legislative Budget
Board (LBB) and the Governor on the
implementation of crisis services
***************************************************

DSHS is adding Performance Measures to the
Performance Contracts for all LMHAs
Contract Performance Measures

Psychiatric hospitalizations after community-based crisis
services:

The percent of persons with a front-door or
community mental health crisis episode at LMHAs
with a State or Community psychiatric hospitalization
within 30 days after the end of the crisis episode.
Exclusions and limitations to contract performance
measures will be noted within Information Item C.
Contract Performance Measures

Linkage to community-based services as appropriate:

The percent of persons with a front-door mental
health crisis episode that is followed by a community
mental health level of care authorization (LOC-A),
and/or a service encounter at a DSHS-funded
substance abuse treatment facility or at an Outreach,
Screening, Assessment and Referral (OSAR)
provider within 14 days of their front-door crisis
episode.
Exclusions and limitations to contract performance
measures will be noted within Information Item C.
Contract Performance Measures

Transition from the crisis assessment to crisis follow-up
services:

The percent of persons with a front-door mental
health crisis episode who have a follow-up community
mental health LOC-A = 5, and who receive a crisis
follow-up service encounter within 30 days of the
crisis assessment.
Exclusions and limitations to contract performance
measures will be noted within Information Item C.
Contract Performance Measures

Psychiatric hospitalizations with/without a crisis
assessment within the community prior to admission:

The percent of persons who have a State or
Community psychiatric hospitalization and have a
crisis assessment within 5 days prior to their
hospitalization. This measure excludes persons
hospitalized who have a community mental health
LOC-A = 1 through 4.
Exclusions and limitations to contract performance
measures will be noted within Information Item C.
Crisis Changes to Report III
Presenters: Natalie Cloudy
Chris Dickinson and
Rod Swan
Community MHSA Contractor Services Section
New Line – Crisis Services
Line 759 Crisis Services
To include all new crisis funding used for
crisis services
New Strategy – Crisis Services
B.2.3 New Crisis Services
To report new Crisis dollars only
Crisis Services – Sub-strategies
Crisis Residential/Inpatient
 Crisis Outpatient
 Crisis Screening and Eligibility
 Crisis Other

Crisis Services – Sub-strategies
Crisis Services – Sub-strategies

The existing Adult and Child Strategies include
the Crisis Sub-strategies:




Crisis Residential/Inpatient
Crisis Outpatient
Crisis Screening and Eligibility
Crisis Other
Crisis Services – Sub-strategies
New Report III Crosswalk
A Mapping Document is in development to
map Encounter Codes, Procedure codes, and
Authority Functions to Report III Substrategies.
FY08 MH Service Array Changes

DSHS is implementing a number of significant
changes to the mental health service array and
to the mental health encounter field definition
documents in FY2008.

To the greatest extent possible, Client Assignment
and Registration (CARE) codes and service grid
codes are being replaced with the American Medical
Association’s industry standard Current Procedural
Terminology (CPT) and Healthcare Common
Procedure Coding System (HCPCS) codes.
FY08 MH Service Array Changes

The negotiated date for full transition from the use of
services grid codes, to the use of procedure codes is
March 1, 2008, which is the beginning of quarter 3.
 For technical assistance, email LMHA encounter
submission contact personnel to:
[email protected]
FY08 MH Service Array Changes

LMHA personnel can find both the FY2008 mental
health service array, and the mental health encounter
field definitions the Mental Retardation and
Behavioral Health Outpatient Warehouse (MBOW).
Both files are in the CA General Warehouse
Information Folder under Specifications.
 INFO_Mental_Health_Service_Array_Combined_F
Y08.xls; and
 INFO_Encounter_Field_Defn_FY08.xls.
FY08 MH Service Array Changes

Any modifications made to the FY2008 mental health
service array document should now be easily
identifiable by the modification date column within the
file.
FY08 MH Service Array Changes
Crisis Services

In the past, any service within the mental health
service array could be reported as delivered in
response to a crisis, just by flagging the service
as a crisis service when reporting the encounter.

Is it ever appropriate to provide a financial benefit
eligibility determination service to an individual in
crisis?
FY08 MH Service Array Changes
Crisis Services

The transition from service grid codes to procedure
codes will only allow for a group of existing services to
be delivered in response to a crisis. The services
available for delivery in response to a crisis will ultimately
be reported by procedure code, and will contain an “ET”
modifier.
FY08 MH Service Array Changes
Crisis Services
These services are:








Psychiatric Diagnostic Interview Examination;
Routine Case Management;
Psychosocial Rehabilitative Services (Rehabilitative
Case Management);
Pharmacological Management;
Administration of an Injection;
Medication Training and Supports;
Individual/Family and Group Counseling; and
Respite Services.
FY08 MH Service Array Changes
Crisis Services

Some existing services are uniquely defined as
services that are provided in response to a
crisis. It is not necessary to report theses
services with the “ET” on the:

Crisis Intervention Services;

Crisis Stabilization Unit Services; and

Crisis Residential Services.
FY08 MH Service Array Changes
Crisis Services

A series of new crisis services have also been added to
the service array as a result of the crisis redesign
initiative. The new crisis services have been added to
the service category ‘Crisis Services,’ which is currently
coded to service grid codes 1505 & 2505:
 Crisis Transportation (staff time, and funding
provided);
 Crisis Follow-Up and Relapse Prevention (one staff,
and second staff);
 Safety Monitoring; and
 Crisis Flexible Benefits (staff time, and funding
provided).
FY08 MH Service Array Changes
Crisis Services

One of the smallest changes made to the
encounter field definitions as a result of the crisis
redesign initiative resulted in one the largest
concerns noted among LMHAs:

The concern was the ability to report accurate
encounter data with the inclusion of the first billed
payer code of CRD (crisis redesign).
 Enhanced crisis services; and
 New crisis services
FY08 MH Service Array Changes
Crisis Services

DSHS acknowledges that the first billed payer
code is a best guess at the time of service
delivery, and as such the first billed payer code
is generally not subject to audit during encounter
data verification.

DSHS may request further information
FY08 MH Service Array Changes
Crisis Services

DSHS expects that Report III will reflect the final
distribution of the funding expended in each of
the categories in the new crisis strategy B.2.3.

Crisis Residential/Inpatient;

Crisis Outpatient;

Crisis Screening and Eligibility; and

Crisis Other.
UM Guidelines for SP0 & 5
Presenters: Molly Lopez
Vicki Belinoski and
Perry Young
Community MHSA Program Services Section
Utilization Management

Utilization Management Guidelines
Children’s Services


Crisis Services: Package 0
Crisis Follow-up Services: Package 5
Children’s Service Package 0
Purpose of Service Package



Brief interventions provided in the community setting
Intended to ameliorate the crisis situation and prevent
utilization of more intensive services
Desired outcome = resolution of the crisis, avoidance
of more intensive and restrictive intervention and
prevention of additional crisis events.
Children’s Service Package 0
Core Crisis Services





Crisis Intervention
Services
Psychiatric Diagnostic
Interview Examination
Pharmacological
Management
Laboratory Services
Safety Monitoring

Crisis Transportation

Crisis Flexible Benefits

Crisis Respite

Extended Observation

Children’s Crisis
Residential
*See UM guidelines grid for expected average utilization
Children’s Service Package 0
Authorization for Crisis Services


These services do not require prior authorization.
However, UM must authorize within 2 business day
of presentation for crisis services. If further crisis
follow-up and relapse prevention services are needed
then the individual may be authorized for Service
Package 5.
Any service offered must meet medical necessity
criteria.
Children’s Service Package 0
Admission Criteria
Diagnosis
 No mental health diagnosis is required.
CA-TRAG
 Meets criteria on CA-TRAG for Service Package 0.
Children’s Service Package 0
Admission Criteria
Special Considerations
 The individual meets the definition of a crisis cited in
the Community Standards Rule:
Crisis--A situation in which:
(A) because of a mental health condition:
(i) the individual presents an immediate
danger to self or others; or
(ii) the individual's mental or physical health is
at risk of serious deterioration; or
Children’s Service Package 0
Admission Criteria
Special Considerations, cont.
 The individual meets the definition of a crisis cited in
the Community Standards Rule:
Crisis--A situation in which:
(B) an individual believes that he or she presents
an immediate danger to self or others or that
his or her mental or physical health is at risk of
serious deterioration.
Children’s Service Package 0
Provider Qualifications




Crisis Intervention Services: QMHP-CS
Pharmacological Management: MD, RN, PA, Pharm-D,
APN, LVN
Psychiatric Diagnostic Interview Examination: LPHA
Safety Monitoring: QMHP-CS or trained
paraprofessional (Behavioral Health Technician)
Children’s Service Package 0
Provider Qualifications, cont.


Extended Observation: Trained paraprofessional
(Behavioral Health Technician)
Crisis Respite: Trained paraprofessional (Behavioral
Health Technician)

Children’s Crisis Residential Services: QMHP-CS

Crisis Transportation: No restrictions
Children’s Service Package 5
Purpose of Service Package


Oriented towards youths who have been discharged
from crisis services or hospitalization
The major focus is on ameliorating the situation that
gave rise to the crisis event, ensuring stability, and
preventing future crisis events.
Children’s Service Package 5
Purpose of Service Package, cont.


Includes ongoing assessment to determine crisis
status and needs, provides time-limited (up to 30
days), brief, solution-focused interventions to
individuals and families
Focuses on providing guidance and developing
problem-solving techniques to enable the individual to
adapt and cope with the situation and stressors that
prompted the crisis event.
Children’s Service Package 5
Core Services





Crisis Follow-up and
Relapse Prevention
Medication Training and
Support
Counseling
Routine Case
Management
Psychiatric Diagnostic
Interview Examination

Pharmacological
Management

Laboratory Services

Crisis Transportation

Crisis Flexible Benefits

Crisis Respite
*See UM guidelines grid for expected average utilization
Children’s Service Package 5
Admission Criteria

The individual has been released from crisis services
or hospitalization and either:


The individual is not eligible for Service Packages
1 – 4; or
The individual has opted to seek services from an
external provider, but continued follow-up is
indicated until referral access is complete.
Children’s Service Package 5
Provider Qualifications







Crisis Follow-up and Relapse Preventions: QMHP-CS
Counseling: LPHA
Routine Case Management: QMHP-CS
Psychiatric Diagnostic Interview Examination: LPHA
Pharmacological Management: MD, RN, PA. Pharm D,
APN, LVN
Medication Training and Support: QMHP-CS, CSSP
Crisis Respite: Trained paraprofessional
Utilization Management

Utilization Management Guidelines
Adult Services


Crisis Services: Package 0
Crisis Follow-up Services: Package 5
Adult Service Package 0
Purpose of Service Package


Services in this package are brief interventions
provided in the community that will ameliorate the crisis
situation and prevent utilization of more intensive
services.
The desired outcome is resolution of the crisis and
avoidance of more intensive and restrictive
interventions or relapse.
Adult Service Package 0
Core Crisis Services





Crisis Intervention
Services
Psychiatric Diagnostic
Interview Examination
Pharmacological
Management
Laboratory Services
Safety Monitoring






Crisis Transportation
Crisis Flexible Benefits
Day Programs for Acute
Needs
Extended Observation
Crisis Residential
Services
Crisis Stabilization Unit
*See UM guidelines grid for expected average utilization
Adult Service Package 0
Authorization for Crisis Services


These services do not require prior authorization.
However, UM must authorize within 2 business day
of presentation for crisis services. If further crisis
follow-up and relapse prevention services are needed
then the individual may be authorized for Service
Package 5.
Any service offered must meet medical necessity
criteria.
Adult Service Package 0
Admission Criteria
Diagnosis
 No mental health diagnosis is required
for admission to Crisis Services.
Adult TRAG
 Meets criteria on Adult TRAG for
Service Package 0.
Adult Service Package 0
Admission Criteria
Special Considerations
 The individual meets the definition of a crisis cited in
the Community Standards Rule:
Crisis--A situation in which:
(A) because of a mental health condition:
(i) the individual presents an immediate
danger to self or others; or
(ii) the individual's mental or physical health is
at risk of serious deterioration; or
Adult Service Package 0
Admission Criteria
Special Considerations, cont.
 The individual meets the definition of a crisis cited in
the Community Standards Rule:
Crisis--A situation in which:
(B) an individual believes that he or she presents
an immediate danger to self or others or that
his or her mental or physical health is at risk of
serious deterioration.
Adult Service Package 0
Provider Qualifications




Crisis Intervention Services: QMHP-CS
Pharmacological Management: MD, RN, PA, Pharm-D,
APN, LVN
Psychiatric Diagnostic Interview Examination: LPHA
Safety Monitoring: QMHP-CS or trained
paraprofessional (Behavioral Health Technician)
Adult Service Package 0
Provider Qualifications, cont.

Extended Observation: Trained paraprofessional
(Behavioral Health Technician)

Crisis Residential Services: QMHP-CS

Crisis Transportation: No restrictions
Adult Service Package 5
Purpose of Service Package


Maintaining the individual’s stability and preventing
further crises and assisting individual’s in obtaining the
services they need.
Crisis follow-up includes ongoing assessment to
determine crisis status and needs, provides timelimited (up to 30 days) brief, solution-focused
interventions.
Adult Service Package 5
Core Services





Crisis Follow-up and
Relapse Prevention
Routine Case
Management
Psychiatric Diagnostic
Interview Examination
Pharmacological
Management
Crisis Transportation





Medication Training and
Support
Counseling – Individual
and Group
Crisis Respite – In-home
Crisis Respite – Not Inhome
Crisis Flexible Benefits
*See UM guidelines grid for expected average utilization
Adult Service Package 5
Admission Criteria
Diagnosis
 Any mental health diagnosis may be used for Crisis
Follow-up eligibility.
Adult TRAG
 Individuals who have been stabilized in SP-0 or who
have been released from psychiatric hospitalization,
and who are not eligible for SP-1 through SP-4
or
Adult Service Package 5
Admission Criteria
Adult TRAG
 Individuals who have been served and stabilized in
SP-0 or released from psychiatric hospitalization and
who are eligible for SP-1 through SP-4 for which there
is no current capacity to provide the service package
they need
or

Individuals who have opted to seek services from
another provider, but continued follow-up is indicated
until referral is completed.
Adult Service Package 5
Admission Criteria
Special Consideration

Medicaid recipients may not be underserved due to
resource limitation.
Adult Service Package 5
Provider Qualifications

Routine Case Management: QMHP–CS or CSSP

Psychiatric Diagnostic Interview: LPHA


Pharmacological Management: MD, RN, PA, Pharm.D,
APN, LVN
Crisis Follow-up and Relapse Prevention: QMHP-CS,
Licensed medical personnel, other personnel (consult
with Program Rules for specific credential
requirement.)
Adult Service Package 5
Provider Qualifications




Medical: Licensed medical personnel
Counseling: LPC, LCSW, LMFT, Licensed
Psychologist, or someone working on the
corresponding licensure under the supervision of a
licensed person.
Crisis Respite: Trained paraprofessional (Behavioral
Health Technician)
Crisis Transportation: No restrictions
Special Projects
Presenter: Lauren Lacefield-Lewis
Community MHSA Program Services Section
Investment Incentive Funding


DSHS has set aside approximately 30% of the
funding from the Legislature for Community
Investment Incentive crisis projects.
Communities must be willing to invest 25% of
the cost of the project in new local resources to
support the crisis services to be eligible for
Psychiatric Emergency Service Center or
proposals for diversion from incarceration or
State hospitalization funds.
Investment Incentive Funding
Of the 30% Community Investment Incentive
Funding


26% will be used to fund Psychiatric Emergency
Service Center or Projects that will divert people from
incarceration prior to booking or State hospitalization
4% will be used to fund Outpatient Competency
Restoration Projects
Investment Incentive Funding
Community Investment Incentive funds will be
reserved for:

Establishment of Psychiatric Emergency Service
Centers,
Projects focusing on diverting individuals from
incarceration prior to booking or alternatives to State
hospitalization, and

Outpatient Competency Restoration programs.

Investment Incentive Funding
Project Selection
DSHS will evaluate all competing requests for
funding to ensure best value for the use of
state funds across the system.
Psychiatric Emergency Services Center






Extent of local and regional collaboration;
Level of coordination with local and regional healthcare
and law enforcement;
Program design, including integration with other local
and regional crisis services;
Size of geographic area to be served;
Size of population to be served; and
Demonstrated need for 23-48 hour observation
services, including utilization of existing capacity in the
region.
Jail & State Hospital Diversion Project
Defined crisis service (e.g. crisis residential service,
Crisis Stabilization Unit, 23-48 hour hold, crisis
respite, or purchase of local hospital beds and
associated services)
 Minimization of officer wait time;
 Local collaboration and support,
 Coordination with judiciary system and law
enforcement;
 Timeliness of implementation; and
 Clinically appropriate program design.

Outpatient Competency Restoration




Demonstrated need;
Integration with existing services;
Level of coordination with judiciary system and law
enforcement; and
Innovation and alignment with evidence-based
practices including the integration of mental health,
substance use treatment and physical health.
Timelines



FY 2008 Q1 requirements for requesting
Community Investment Incentive funds
provided to LMHAs and NorthSTAR
FY 2008 Q1 requirements for requesting
Outpatient Competency Restoration funds
provided to LMHAs and NorthSTAR
FY 2008 Q2 proposal for funding due to DSHS
– Friday February 29, 2008
Timelines

FY 2008 Q3 Community Investment Incentive
projects selected by DSHS

FY 2008 Q4 Sites selected notified

FY 2008 Q3 Contract Amendments executed

FY 2008 Q4 Community Investment Incentive
projects begin implementation
Thanks for joining us today.
For more information on Crisis Redesign
& Competency Restoration
Consult the following web page:
http://www.dshs.state.tx.us/mhsacsr/default.shtm