1. Yes Waiver Preparing for Statewide Roll Out
Department of state Health services
In collaboration with UT-Texas Institute for Excellence in Mental Health

2. Introduction
Carmen Bliss, LMSW
Jennifer Martinez

3. Carmen Bliss, LMSW Jennifer Martinez
Youth Empowerment Services (YES) Waiver
Carmen Bliss, LMSW
Jennifer Martinez

4. Statewide by FY2016
Rider 80 of the 83R legislative session directed the Health and Human Services Commission (HHSC) and Department of State Health Services (DSHS) to initiate the statewide expansion of the Youth Empowerment Services waiver. The specific language of the Rider states:
1915(c) Youth Empowerment Services Waiver Expansion. The Health and Human Services Commission, in conjunction with the Department of State Health Services, shall initiate the expansion of the 1915(c) Youth Empowerment Services (YES) waiver statewide during the biennium. Expansion into new service areas is contingent upon approval by the Centers for Medicare and Medicaid Services (CMS).
While awaiting approval of expansion of YES Waiver as a Medicaid program by Centers for Medicare and Medicaid Services (CMS), DSHS will expand as a general revenue funded program.
Meeting the needs of Texas

5. Overview of 1915(c) Waiver
Legislative direction to the Health and Human Services Commission (HHSC) – prevent custody relinquishment of children with Severe Emotional Disturbance (SED)
HHSC authorized DSHS to develop and operate a 1915(c) waiver for children with SED
YES Waiver provides home and community-based services to children who otherwise need institutional care (e.g., psychiatric inpatient care) or whose parents would turn to state custody for care
Must be cost neutral to Medicaid (average Medicaid service cost with waiver less than or equal to average Medicaid service cost w/o waiver)
Currently implemented in Bexar, Travis, Fort Bend, Harris, Brazoria, Galveston, Cameron, Hidalgo, Willacy and Tarrant Counties
Submitting waiver amendments to CMS for expansion into Burnet, Williamson, and McClennan counties
Will continue to submit waiver amendments until all expansion into all Texas counties is complete

6. YES Waiver Goals
Provide a more complete continuum of flexible community-based services and supports for children and adolescents with SED and their families
Ensure access to other flexible non-traditional support services, including the parent partners
Develop individualized plans of care (IPC) through a family-centered planning process
Prevent or reduce inpatient psychiatric admissions for children and adolescents with SED
Reduce and prevent out-of-home placements by all child-serving agencies
Improve the clinical and functional outcomes of children and adolescents

7. YES Waiver Service Array
Respite (In-Home and Out-Of-Home);
Adaptive Aids and Supports;
Community Living Supports;
Specialized Therapies (Animal Assisted Therapy, Art Therapy, Music Therapy, Recreational Therapy, Nutritional Counseling);
Employment Assistance;
Family Supports;
Minor Home Modifications;
Non-Medical Transportation;
Paraprofessional Services;
Supportive Employment;
Transitional Services
Supportive Family-based Alternative;

8. Timeline & Role of UT: Texas Institute for Excellence in Mental Health (TIEMH)
Erin Espinosa, PH.D.
UT-TIEMH

11. Activities Receive S-Kit and Implementation Workbook
Turn in completed Implementation Workbook to TIEMH
TIEMH reviews Implementation Workbook and submits Process and Organizational questions for review and consideration
Regional In-Person Planning and Strategy meeting
Process and organizational support calls with TIEMH

12. TIEMH Tools
Bonnie Evans, MPsych
UT-TIEMH

13. IMPLEMENTATION TOOLS Implementation Workbook
Texas Institute of Excellence in Mental Health (TIEMH) /
University of Texas at Austin
IMPLEMENTATION TOOLS
Implementation Workbook
Organizational overview / readiness for YES Waiver
Leadership
Community Engagement
Wraparound Teams
YES Provider Network
Plan for Targets
Quality Indicators
Next Steps

14. YES Starter-Kit (S-KIT)
The ‘How to’ of YES Waiver
Roles & Definitions
Identifying & Developing a Provider Network
Inquiry Line
High Quality Wraparound
Marketing & Community
YES Eligibility Criteria
Medicaid
Resources (Data Scan, Safety/Crisis Plans)
Statewide Expansion Timeline

15. TIEMH TEAM
Rebecca Marquez, M.Ed.
UT-TIEMH

16. Texas Institute for Excellence in Mental Health
Erin Espinosa, Ph.D.
Research Associate
Rebecca Marquez, M.Ed.
Implementation Specialist: Wraparound
(main line)
Bonnie Evans, MPsych
Implementation Specialist: YES Waiver
Texas System of Care Website:

17. Provider Networks
Jennifer Martinez, DSHS
Kim Garrett, DSHS

18. Yes Waiver Provider Network
YES Service Array
Provider Qualifications
Building a provider Network
IDD providers
Existing staff members
Relatives and trusted friends of waiver participants
Graduate Students
Employees with known flexible schedules
Professional Associations

19. YES Service Array Respite (In-Home & Out-Of-Home)
Adaptive Aids and Supports
Community Living Supports
Family Supports
Minor Home Modifications
Non-Medical Transportation
Paraprofessional Services
Specialized Therapies
Animal Assisted Therapy
Art Therapy
Music Therapy
Recreational Therapy
Nutritional Counseling
Supportive Family-based Alternative
Transitional Services

20. Respite
Respite is furnished on a short-term basis because of the absence or need for relief of those persons who normally provide care for the Waiver participant.
In-Home Respite:
May be provided in the individual’s home or place of residence
May be provided in the private residence of a respite care provider if that provider is a relative of the participant
Is an excellent resource that has long-lasting potential benefits
Out-of-Home Respite:
May be provided in:
Foster homes licensed by DFPS
General Residential Operations licensed by DFPS
Day or overnight camps accredited by the ACA
Child care centers/homes licensed by DFPS
Are more available in some areas than others
Translation: this is for the relief of the LAR, although the client may benefit as well.
Out-of-Home respite is more readily available in some areas than in others.
In-Home respite is an excellent resource and ha

21. Adaptive Aids and Supports
Devices and supports recommended by the treatment team that contribute to the improved functioning of the Waiver participant in the community as a service under the approved Service Authorization.
Therapeutic Peer Support
Provides fees to facilitate the participant’s involvement in peer support activities such as specialized groups (i.e., dance class, scouts)
Therapeutic Equipment/Supplies
Provides fees for items necessary to execute and/or maintain the participant’s treatment plan and to help the participant achieve therapy goals (i.e., art supplies, basketball)
Note: Minor Home Modifications and Adaptive Aids and Supports have a collective limit of $5,000 annually

22. Community Living Supports
May be provided in the participant’s home or community
CLS training may be provided to participant and/or LAR
CLS may train in skills related to care of the waiver participant for family members (i.e., parenting skills)
CLS may train in skills related to ADLs, IADLs, communication, relationship-building, and integration into community activities (i.e., anger control, anxiety reduction)
All CLS supports should be targeted at enabling the participant to attain or maintain maximum potential
All CLS training is presented by staff who have a solid understanding of participant’s goals and have the education and knowledge to assist in their attainment. May include evidence-based practices, a structured curriculum, and best practices
Documentation must justify the necessity of the high level of support provided by Community Living Supports
Qualified Mental Health Professional - Community Services

23. Family Supports
Family Supports provides peer mentoring and support to the primary caregivers by:
Modeling self-advocacy skills
Modeling advocacy for Waiver participant
Providing information
Providing referrals
Providing non-clinical skills training and role modeling
a high school diploma, or a high school equivalency certificate
at least one cumulative year of receiving or navigating mental health community services
be under the direct clinical supervision of a master's level therapist

24. Minor Home Modifications
These services include Home Accessibility / Safety Adaptations - Physical adaptations to the Waiver participant's residence that are necessary to ensure the health, welfare and safety of the participant.
Minor Home Modifications must be age appropriate and related to specific therapeutic goals
The Waiver Provider is required to maintain written documentation of reasonable cost for services
Examples are door chimes, room dividers, and doorway gates
Note: Minor Home Modifications and Adaptive Aids and Supports have a collective limit of $5,000 annually

25. Non-Medical Transportation
Non-Medical transportation enables Waiver participants to gain access to Yes Waiver and other community services, activities and resources.
Transportation providers must have a valid Texas driver's license and insurance appropriate to the vehicle used to provide transportation
Transportation may be provided to YES Waiver activities identified on the Service Authorization
Transportation is best provided with natural resources
Transportation does not include any other medical transportation under the State plan

26. Paraprofessional Services
Paraprofessional Services are essential to promote community inclusion in typical child/youth activities and exceed what would normally be available for children and adolescents in the community.
Services include skilled mentoring and coaching as well as preventing and managing behaviors stemming from a serious emotional disturbance.
a high school diploma, or a high school equivalency certificate
minimum of one year of full-time experience in the provision of activities to a population similar to those served under this waiver
demonstrate competency in the provision and documentation of the specified or comparable service

27. Specialized Therapies
Animal Assisted Therapy ~ Art Therapy ~ Music Therapy ~
Recreational Therapy ~ Nutritional Counseling
The intent of these services is to maintain or improve health, welfare, and/or effective functioning in the community.
Licensed professionals, with documented training and experience relative to the specialized therapies identified above, or
Individuals who meet the appropriate certification standards listed below:
Art Therapy Credentials Board (AT-BC)
Certification Board for Music Therapists (MT-BC)
Pet Partners program, Equine Assisted Growth and Learning Association (EAGALA), and the North American Riding for the Handicapped Association (NARHA)
National Council of Therapeutic Recreation Certification (CTRS). Texas Certified Therapeutic Recreation Specialist (TRS/TXC)
Texas Board of Examiners of Dietitians

28. Supportive Family-based Alternative
SFA are designed to provide therapeutic support to the Waiver participant, often when the family is at its wit’s end. They are designed to model appropriate behaviors for the Waiver participant and the family with the objective of enabling the Waiver participant to successfully return to their family and live in the community with their family.
Facilitated by a DFPS licensed Child-Placing Agency
Provide therapeutic support to the child and caregiver to model appropriate behaviors
May be authorized up to 90 consecutive days or cumulative days per individual service plan per year
Note: Although the participant is with a Child-Placing Agency, the child is NOT being placed in any form of foster care

29. Transitional Services
A one time non–recurring allowable expense when a Waiver participant transitions from the family home, an YES Waiver approved institution, or a provider-operated setting to their own private community residence
Services Provided must meet the requirements of the approved service authorization and are of reasonable cost
Assistance may include:
Utility and security deposits for the home/apartment; rent is not included
Needed household items such as linens and cooking utensils
Essential furnishings
Moving Expenses
Services Necessary to ensure health and safety in the apartment/home (e.g., pest eradication, allergen control, one-time cleaning)
Transitional assistance is limited to $2500 per waiver participant and a transition plan must be in place

30. Yes Waiver
A strong Provider Network enables the YES Waiver to provide intensive community-based services for children and adolescents with SED.
A strong Provider Network allows more flexibility for families and prevents or reduces the institutionalization of children and adolescents with SED.
The input of the entire Wraparound Team in carefully selecting services maximizes the opportunity for the YES Waiver participant and family to be successful.

31. LMHA Responsibilities
Candis Guidry, DSHS
Christine Medeiros, DSHS

32. LMHA Responsibilities Webinar January 27, 2015

33. LMHA Administrative Activities
Recruit Waiver Providers & Potential Waiver Recipients
Maintain Local Inquiry List
Determine Clinical Eligibility and Recommend a Level of Care
Coordinate with DSHS to obtain Medicaid eligibility
Present Choice Options to Client
Waiver Services
Institutional Services
Other Non-Waiver Services
Complete Service Authorizations for each participant
Provide Intensive Case Management using the National Wraparound model
Transition Planning
Conduct Utilization Management, Quality Assurance & Improvement Activities
Direct enter into CMBHS (CED, POC, & Service Notes if provider)
Assist with Recruiting Waiver Providers
Talking with area providers about the program
Referring interested providers to the Open Enrollment Kit
Recruit Potential Waiver Participants
A. from within LMHA
B. Sharing with community shareholders: ISD, Juvenile Justice, Psy. Hospitals, CPS, Community Resource Coordination Groups (CRCG).
3. Manage and maintain an Inquiry List of individuals who are seeking Waiver services;
4. Facilitate waiver enrollment of interested individuals by completing all activities necessary for waiver enrollment (Demographic, Financial & Clinical Eligibility);
Assist clients in obtaining and maintaining Medicaid eligibility (Children and youth with Medicaid who are enrolled in YES are entitled to the behavioral health services available in Texas Resilience and Recovery (TRR) and are authorized in LOC-YES to reflect access to those services;
Complete Waiver Forms demonstrating choice;
Facilitate the development of Service Authorizations;
Provide Intensive Case Management using the Wraparound Planning Process;
Provide transition planning and service coordination beginning at least six months prior to the Waiver participant’s 19th birthday;
Perform QM and UM oversight activities;
Clinical Management of Behavioral Health Services data entry
Additional responsibilities if LMHA is the Comprehensive Waiver Provider for YES Waiver Services

34. Referrals and Inquiry List
Individuals requesting services under the YES Waiver may or may not be current clients of the LMHA. The LMHA should provide information about the YES Waiver to any client that may be eligible for the YES Waiver.
The LMHA may receive referrals of individuals requesting the YES Waiver from outside agencies, organizations, or providers; however, the Legally Authorized Representative (LAR) or individual must make the telephone call to be placed on the Inquiry List.
Individuals may present to the LMHA requesting the YES Waiver without a referral.
Register each individual on the Inquiry List that contacts the LMHA based on the date and time the phone call was received.
The LMHA must submit a current and up-to-date Inquiry List to DSHS on the last business day of each month.
Show inquiry list
Be sure to stress that calls should be answered in the order received. This kind of implies that, but to avoid confusion, it should be made clear.
The LMHA must submit a current and up to date Inquiry List to DSHS on the last business day of each month.

35. Enrollment
1. Must enroll and serve in the YES Waiver a minimum average of clients (based on 5% of Children Services Targets). All YES Waiver participants served will count toward overall Children’s Services targets except where clients over the age of 18 are authorized into an Adult Level of Care.
2. An enrolled and served client is defined as a client with a submitted and approved Initial Service Authorization.
3. Must submit Service Authorizations in accordance with the YES Waiver Policy and Procedure Manual.
4. Must continue to assess and, if found to be eligible, enroll clients in excess of their minimum enrollment requirement in accordance with Inquiry List Management policies.
5. Must not maintain a wait list for YES Waiver enrollment.

36. Key to Success: Wraparound
Intensive Case Management to client ratio of 1:10
The Wraparound Facilitator leads the comprehensive Child and Family Team Meeting with the identified team members to develop, but is not limited to, the identification of goals and objectives, Crisis/Safety Planning, and the development of the Service Authorization, and its ongoing monitoring.
Service Authorization development includes:
The identification of types of YES Waiver services;
The identification annual quantity of YES Waiver services;
Calculations of annual cost for proposed services;
State Plan Services;
Non-Waiver services (i.e., DSHS general revenue flexible funds);
Sustainability through natural supports and community resources for transition planning.
Texas Department of State Health Services (DSHS)

37. Quality Management Plan
Each LMHA must have a Quality Management Plan that includes compliance and improvement activities for the YES Waiver.
DSHS YES Waiver Program approves each LMHA’s QM Plan for the YES Waiver.

38. QM & UM Activities Critical Incident Reporting Inquiry List
Clinical Eligibility
Service Authorization
Waiver Service Provision
Wraparound Plan
Crisis/Safety Plan
Engagement
Critical Incident Reporting
Termination Reasons
Provider Credentialing & Training
Utilization Patterns
Treatment outcomes
Service claims
Inquiry List: Timely access to clinical eligibility and services
Service Authorization incorporates Wraparound Planning with Child & Family Team
Crisis/Safety Plans: Because these youth are at high risk of placement for mental health treatment or are returning from such placements,
crisis and safety plans are developed at the first meeting of the treatment teams. A crisis plan focuses on planning
for, predicting, and preventing the occurrence of a crisis.

39. Experience from an LMHA
Monica Rodriguez, Tropical Texas Behavioral Health

40. Question & Answer
Carmen Bliss, DSHS

41. THANK YOU For joining us today!!