Subtitle
Title
1
Professional Development & Training Series:
Behavioral Health Quality Assurance (BHQA) Staff
Workshop #4: Short-Doyle Medi-Cal Rehabilitation Option &
Targeted Case Management Manual (1993):
June 2017
San Francisco Department of Public Health
Behavioral Health Services
Quality Management
Clinical Documentation Improvement Program (CDIP)
Staff contact: Joseph A Turner, PhD ([email protected])
Handouts
Build a binder for workshop materials:
Powerpoint: steal these slides for your training!
CDIP SDMC Rehab/TCM Manual Excerpts: a must-
have reference for a true QA professional
Bonus Info: Kaiser Family Foundation Report
(Rehab Option) + DHCS Information Notices Tool
Staff Contact: Joseph A Turner, PhD ([email protected]) 6/8/2017 2
Recap on the Series
Problem: People Do Not Understand…
Quality assurance…
Managed care…
BHQA staff deserve education, training & support:
Workshop 1: don’t have to memorize CCR Title 9, but…
Workshop 2: don’t have to our Medicaid State Plan, but …
Workshop 3: don’t have to memorize MHP Boilerplate, but…
Workshop 4: you don’t have to memorize the Short-Doyle
Medi-Cal Rehab Option/TCM Manual, but…
Staff Contact: Joseph A Turner, PhD ([email protected]) 6/8/2017 3
Jargon Check: Quality Assurance
4
…retrospective
comparison against
a standard
…real-time
investigation of
processes
…organized
system to monitor
& improve quality
6/8/2017Staff Contact: Joseph A Turner, PhD ([email protected])
5
Recap on the Series
6/8/2017
Federal
State
County
Provider
Workshop #1 Workshop #2 Workshop #3 Workshop #4 Workshop #5
State Plan
CCR Title 9Boilerplate
Contract
1994
SDMC
Manual
Medi-Cal
Certification
Staff Contact: Joseph A Turner, PhD ([email protected])
6
Recap: Workshop #1
“CCR Title 9”
(a regulation)
Blueprint (build a County Mental Health Plan)
Rules(operate a County Mental Health Plan)
You build a publicly funded managed care
Medicaid program by following blueprints & rules!
Recap: Workshop #1
7
The 27 Regulatory “Titles” of the California Code of Regulations (CCR)
Title 1: General Provisions Title 15: Crime Prevention & Corrections
Title 2: Administration Title 16: Professional & Vocational Regulations
Title 3: Food & Agriculture Title 17: Public Health
Title 4: Business Regulations Title 18: Public Revenues
Title 5: Education Title 19: Public Safety
Title 7: Harbors & Navigation Title 20: Public Utilities & Energy
Title 8: Industrial Relations Title 21: Public Works
Title 9: Rehabilitative & Developmental Services Title 22: Social Security
Title 10: Investment Title 23: Waters
Title 11: Law Title 24: Building Standards Code
Title 12: Military & Veterans Affairs Title 25: Housing & Community Development
Title 13: Motor Vehicles Title 26: Toxics
Title 14: Natural Resources Title 27: Environmental Protection
Regulations =
BLUEPRINTS &
RULES
6/19/2017Staff Contact: Joseph A Turner, PhD ([email protected])
8
Switching Gears…
If CCR Title 9 functions as
“blueprints and rules” for SMHS…
…what were the blueprints and rules for CCR Title 9?
…what preceded CCR Title 9?
6/8/2017Staff Contact: Joseph A Turner, PhD ([email protected])
Tracking Down Jargon
How to understand “service necessity”
How to understand “case management brokerage”
Connecting with History and Context
How to understand County “Carve Out”
What did Medi-Cal look like before?
Staff Contact: Joseph A Turner, PhD ([email protected]) 9
Backstory on the SDMC-
Rehab Option/TCM Manual
Manuals & Page-by-Page Updates
Guidance published in “manuals” that get updated over
time—only specific pages get updated
Staff Contact: Joseph A Turner, PhD ([email protected]) 10
Backstory on the SDMC-
Rehab Option/TCM Manual
SDMC Rehab Option TCM Manual
CDIP tried to obtain all the pages (original and
updated)…
Partially successful
CDIP marked up the document to show:
original language that was updated,
updates from July 1995 and
updates from October 1995Staff Contact: Joseph A Turner, PhD ([email protected]) 11
Backstory on the SDMC-
Rehab Option/TCM Manual
Frankensteinian monster?
Staff Contact: Joseph A Turner, PhD ([email protected]) 12
Backstory on the SDMC-
Rehab Option/TCM Manual
Don’t let perfection be the enemy of good!
Staff Contact: Joseph A Turner, PhD ([email protected]) 13
Backstory on the SDMC-
Rehab Option/TCM Manual
Cover sheet
explains how
CDIP created
our local copy of
the manual
Staff Contact: Joseph A Turner, PhD ([email protected]) 14
Structure of the
SDMC-Rehab Option/TCM ManualSECTION TITLE (Compact)
1
Introduction
Acknowledgements
Philosophy
2
Service Definitions *
Planned Services*
Unplanned Services*
Targeted Case Management*
Comparison of Service Functions*
Lockouts, Overrides, Computer Edits, and Other Limitations
Staffing Qualifications for Service Delivery and Documentation
3 Medical and Service Necessity *
4
Coordinated Services Summary*
Personnel Description-Coordinated Services*
Quality Management System-Coordinated Services *
Documentation Standards-Coordinated Services*
5Short-Doyle/Medi-Cal Traditional Quality Assurance and Utilization Review
Requirements for Rehabilitation and Case Management/Brokerage*6 Inpatient Hospital UR Requirements7 Provider Certification Standards*8 Definitions*9 Index
* selected
pages are
included in
workshop
handout
get the full
copy @CDIP
website
Expansion of Billable Services
Moving from Clinic Option to Rehab Option
Expansion of “Case Management/Brokerage”
Quality Assurance & Utilization Review
Models
“Traditional” vs. “Coordinated Services”
Staff Contact: Joseph A Turner, PhD ([email protected]) 15
SDMC-Rehab Option/TCM
Manual: Key Concepts
The “necessity”
Medical vs. service necessity
The domains of impairment
Derived from the Community Functioning Evaluation
(CfE)
Staff Contact: Joseph A Turner, PhD ([email protected]) 16
SDMC-Rehab Option/TCM
Manual: Key Concepts
Staff Contact: Joseph A Turner, PhD ([email protected]) 17
Expanding Services-
M-Caid Rehab vs. Clinic Option*
Service Clinic Option Rehab Option
Inpatient Psych Hospital yes yes
Psych Health Facility no yes
Adult Residential no yes
Adult Crisis Residential no yes
Day Treatment no yes
Mental Health Services ish yes
Crisis Stabilization no yes
Case Management only client client or sig other
*see page 2-43 of Manual to see table
Rehab vs. Clinic Option Flexibility
More types of services (beyond inpatient and limited
outpatient)
More types of service providers (beyond
MD/PhD/LCSW)
More locations for services (beyond the clinic walls)
Staff Contact: Joseph A Turner, PhD ([email protected]) 18
Expanding Services-
M-Caid Rehab vs. Clinic Option
Formal “Case Management”
Elements of Targeted Case Management:
Assessing, planning, brokering, monitoring
Rehabilitation Option services include
services that are “case management-like”
Managing/monitoring Medicaid planned services (e.g., Plan
Development; Assessment of case management needs)
Staff Contact: Joseph A Turner, PhD ([email protected]) 19
Expanding Services-
Rehab + TCM
Limits of Rehab Option Services
“…activities geared toward gaining access to and
monitoring non-Medicaid services are not reimbursable
under the rehabilitation option”
“California has chosen to include linkage to both Medicaid
and non-Medicaid services under a Case
Management/Brokerage service function…billed as
Targeted Case Management…rather than Rehabilitation
Option.
Staff Contact: Joseph A Turner, PhD ([email protected]) 20
Expanding Services-
Rehab + TCM
Targeted Case Management/Brokerage
Linkage and Consultation: identification and pursuit of
resources including:
Interagency and intra-agency consultation, communication,
coordination and referral
Monitoring service delivery system to ensure client’s access to
service/delivery system
Monitoring client’s progress
Plan Development
Staff Contact: Joseph A Turner, PhD ([email protected]) 21
Expanding Services-
Rehab + TCM
Targeted Case Management/Brokerage
Placement Services: supportive assistance to the client in the assessment and determination of need and securing adequate and appropriate living arrangements including:
Locating/securing appropriate living environment
Locating/securing funding
Preplacement visits
Negotiation of housing placement contracts
Placement and placement follow-up
Accessing services necessary to secure placement
Staff Contact: Joseph A Turner, PhD ([email protected]) 22
Expanding Services-
Rehab + TCM
Targeted Case Management/Brokerage
Staff Contact: Joseph A Turner, PhD ([email protected]) 23
Expanding Services-
Rehab + TCM
Activity How to Bill
(Re)Evaluation Mental Health Services (Rehab)
Plan Development Mental Health Services (Rehab)
Linkage and Consultation Case Management/Brokerage
Placement Services Case Management/Brokerage
Assistance with Daily Living Mental Health Services (Rehab)
Emergency Intervention Crisis Intervention
*see manual page 2-42
Coordinated Services Approach to QA/UR
Staff Contact: Joseph A Turner, PhD ([email protected]) 24
Quality Assurance & Utilization
Review Models
Neighborhood-
Based County
Clinics Intake
Coordination
Plan
Service
Plan
• Clients access services through clinics based in
neighborhoods
• Coordinator conducts intake over 60 days
• Coordination Plan identifies their life desires and how mental
health services can help
• Coordinator puts every service/service provider on plan
Coordinated Services Approach to QA/UR
Staff Contact: Joseph A Turner, PhD ([email protected]) 25
Quality Assurance & Utilization
Review Models
Neighborhood-
Based County
Clinics Intake
Coordination
Plan
Service
Plan
• Utilization Review:
• At intake/annually, is there medical necessity?
• At intake/annually, authorize services
• Utilization Control:
• Coordinator must give prior approval for all services (except
TCM)
Traditional QA Approach to QA/UR
Missing pages from manual make it hard to see
(Section 5)
Closer to what we experience today?
Staff Contact: Joseph A Turner, PhD ([email protected]) 26
Quality Assurance & Utilization
Review Models
Staff Contact: Joseph A Turner, PhD ([email protected]) 27
Quality Assurance & Utilization
Review Models
Staff Contact: Joseph A Turner, PhD ([email protected]) 28
The Necessity
Medical Necessity Service Necessity
• Definition: individual’s level of
functioning, due to a mental
illness, disrupts or interferes
with community living to the
extent that without service, the
Individual would be unable to
maintain residence, engage in
productive activities and daily
responsibilities, maintain a
social support system, and keep
healthy
• 2 Criteria to Meet: diagnostic
and impairment criteria
• Definition: to be eligible for
reimbursement of Case
Management/Brokerage, the
Individual must meet A&B of the
necessity criteria.
• Note: all individuals with medical
necessity also have service
necessity
Staff Contact: Joseph A Turner, PhD ([email protected]) 29
The Necessity
Medical Necessity Service Necessity
• seems to be about mental
health services, crisis
intervention, etc.
• clearly about TCM
Medical Necessity
Impairment Criteria
6/19/2017 30
Impairment in Community Functioning
Criteria (one of the following)
a. Community Functioning: (next page)
b. Psychiatric Symptoms: the person exhibits repeated presence
of psychotic symptoms OR suicidal ideation or acts OR violent
ideation or acts to persons or property.
c. Psychiatric History: the person has a psychiatric history of
recurring substantial functional impairment or symptoms. The
person's history demonstrates that without mental health service,
there is a high risk of recurrence to a level of functional
impairment/symptoms listed above.
OR
OR
Medical Necessity
Impairment Criteria
6/19/2017 31
Community Functioning: reflects the degree in which a mental health illness disrupts or
interferes with community living to the extent that without treatment and/or services, the person
would be unable to function:
(a) Living arrangements: the person lives in the community in a setting of his/her choice; for
children, they live in the home and comply with community rules
(b) Daily Activities: the person is involved in a productive daily activities (may include
involvement in household chores, scheduled programs, education and training, and employment;
for children, they are involved in age appropriate daily activities (may include involvement in
household chores, scheduled programs, education and training, and employment)
(c) Social Relationships: the person demonstrates the ability to establish and maintain
relationships and social support systems; for children, they demonstrate the ability to establish and
maintain relationships and social support systems; for children, they demonstrate the ability to
establish and maintain age appropriate social and family relationships
(d) Health: individual demonstrates the ability to maintain physical and mental hygiene and
manage own medications; for children, they experience maximum physical and mental well being,
with symptoms minimized and good access to health care services.
32
Parting Thoughts…
The SDMC Rehab Option & TCM
Manual is your friend!
6/8/2017Staff Contact: Joseph A Turner, PhD ([email protected])
SFDPH-BHS-CDIP Website:
Not a “buffet” (i.e., take what you want)
Is “pre fixe” (i.e., the chef gives you)
https://www.sfdph.org/dph/comupg/oservices/mentalHlth/CBHS/CBHSQualityMgmt.asp
Staff Contact: Joseph A Turner, PhD ([email protected]) 33
Our Resources