3 Carmen Bliss, LMSW Jennifer Martinez Youth Empowerment Services (YES) WaiverCarmen Bliss, LMSWJennifer Martinez
4 Statewide by FY2016Rider 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) WaiverLegislative 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 SEDYES 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 careMust 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 CountiesSubmitting waiver amendments to CMS for expansion into Burnet, Williamson, and McClennan countiesWill continue to submit waiver amendments until all expansion into all Texas counties is complete
6 YES Waiver GoalsProvide a more complete continuum of flexible community-based services and supports for children and adolescents with SED and their familiesEnsure access to other flexible non-traditional support services, including the parent partnersDevelop individualized plans of care (IPC) through a family-centered planning processPrevent or reduce inpatient psychiatric admissions for children and adolescents with SEDReduce and prevent out-of-home placements by all child-serving agenciesImprove 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 ServicesSupportive 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 TIEMHTIEMH reviews Implementation Workbook and submits Process and Organizational questions for review and considerationRegional In-Person Planning and Strategy meetingProcess and organizational support calls with TIEMH
13 IMPLEMENTATION TOOLS Implementation Workbook Texas Institute of Excellence in Mental Health (TIEMH) /University of Texas at AustinIMPLEMENTATION TOOLSImplementation WorkbookOrganizational overview / readiness for YES WaiverLeadershipCommunity EngagementWraparound TeamsYES Provider NetworkPlan for TargetsQuality IndicatorsNext Steps
14 YES Starter-Kit (S-KIT) The ‘How to’ of YES WaiverRoles & DefinitionsIdentifying & Developing a Provider NetworkInquiry LineHigh Quality WraparoundMarketing & CommunityYES Eligibility CriteriaMedicaidResources (Data Scan, Safety/Crisis Plans)Statewide Expansion Timeline
16 Texas Institute for Excellence in Mental Health Erin Espinosa, Ph.D.Research AssociateRebecca Marquez, M.Ed.Implementation Specialist: Wraparound(main line)Bonnie Evans, MPsychImplementation Specialist: YES WaiverTexas System of Care Website:
18 Yes Waiver Provider Network YES Service ArrayProvider QualificationsBuilding a provider NetworkIDD providersExisting staff membersRelatives and trusted friends of waiver participantsGraduate StudentsEmployees with known flexible schedulesProfessional Associations
19 YES Service Array Respite (In-Home & Out-Of-Home) Adaptive Aids and SupportsCommunity Living SupportsFamily SupportsMinor Home ModificationsNon-Medical TransportationParaprofessional ServicesSpecialized TherapiesAnimal Assisted TherapyArt TherapyMusic TherapyRecreational TherapyNutritional CounselingSupportive Family-based AlternativeTransitional Services
20 RespiteRespite 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 residenceMay be provided in the private residence of a respite care provider if that provider is a relative of the participantIs an excellent resource that has long-lasting potential benefitsOut-of-Home Respite:May be provided in:Foster homes licensed by DFPSGeneral Residential Operations licensed by DFPSDay or overnight camps accredited by the ACAChild care centers/homes licensed by DFPSAre more available in some areas than othersTranslation: 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 SupportProvides fees to facilitate the participant’s involvement in peer support activities such as specialized groups (i.e., dance class, scouts)Therapeutic Equipment/SuppliesProvides 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 communityCLS training may be provided to participant and/or LARCLS 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 potentialAll 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 practicesDocumentation must justify the necessity of the high level of support provided by Community Living SupportsQualified Mental Health Professional - Community Services
23 Family SupportsFamily Supports provides peer mentoring and support to the primary caregivers by:Modeling self-advocacy skillsModeling advocacy for Waiver participantProviding informationProviding referralsProviding non-clinical skills training and role modelinga high school diploma, or a high school equivalency certificateat least one cumulative year of receiving or navigating mental health community servicesbe 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 goalsThe Waiver Provider is required to maintain written documentation of reasonable cost for servicesExamples are door chimes, room dividers, and doorway gatesNote: 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 transportationTransportation may be provided to YES Waiver activities identified on the Service AuthorizationTransportation is best provided with natural resourcesTransportation 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 certificateminimum of one year of full-time experience in the provision of activities to a population similar to those served under this waiverdemonstrate 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 CounselingThe 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, orIndividuals 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 AgencyProvide therapeutic support to the child and caregiver to model appropriate behaviorsMay be authorized up to 90 consecutive days or cumulative days per individual service plan per yearNote: 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 residenceServices Provided must meet the requirements of the approved service authorization and are of reasonable costAssistance may include:Utility and security deposits for the home/apartment; rent is not includedNeeded household items such as linens and cooking utensilsEssential furnishingsMoving ExpensesServices 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 WaiverA 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.
33 LMHA Administrative Activities Recruit Waiver Providers & Potential Waiver RecipientsMaintain Local Inquiry ListDetermine Clinical Eligibility and Recommend a Level of CareCoordinate with DSHS to obtain Medicaid eligibilityPresent Choice Options to ClientWaiver ServicesInstitutional ServicesOther Non-Waiver ServicesComplete Service Authorizations for each participantProvide Intensive Case Management using the National Wraparound modelTransition PlanningConduct Utilization Management, Quality Assurance & Improvement ActivitiesDirect enter into CMBHS (CED, POC, & Service Notes if provider)Assist with Recruiting Waiver ProvidersTalking with area providers about the programReferring interested providers to the Open Enrollment KitRecruit Potential Waiver ParticipantsA. from within LMHAB. 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 entryAdditional 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 listBe 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 Enrollment1. 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 1:10The 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 EligibilityService AuthorizationWaiver Service ProvisionWraparound PlanCrisis/Safety PlanEngagementCritical Incident ReportingTermination ReasonsProvider Credentialing & TrainingUtilization PatternsTreatment outcomesService claimsInquiry List: Timely access to clinical eligibility and servicesService Authorization incorporates Wraparound Planning with Child & Family TeamCrisis/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 planningfor, predicting, and preventing the occurrence of a crisis.
39 Experience from an LMHA Monica Rodriguez, Tropical Texas Behavioral Health