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

Introduction Carmen Bliss, LMSW Jennifer Martinez

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

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 2014-15 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

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

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

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;

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

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

TIEMH Tools Bonnie Evans, MPsych UT-TIEMH

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

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

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

Texas Institute for Excellence in Mental Health Erin Espinosa, Ph.D. Research Associate erin.espinosa@austin.utexas.edu 512-232-0606 Rebecca Marquez, M.Ed. Implementation Specialist: Wraparound rebecca.marquez@austin.utexas.edu 512-232-8309 (main line) Bonnie Evans, MPsych Implementation Specialist: YES Waiver bonnie.evans@austin.utexas.edu 512-232-8327 Texas System of Care Website: http://www.txsystemofcare.org/

Provider Networks Jennifer Martinez, DSHS Kim Garrett, DSHS

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

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

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

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

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

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

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

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

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

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

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

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

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.

LMHA Responsibilities Candis Guidry, DSHS Christine Medeiros, DSHS

LMHA Responsibilities Webinar January 27, 2015

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

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.

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.

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)

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.

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.

Experience from an LMHA Monica Rodriguez, Tropical Texas Behavioral Health

Question & Answer Carmen Bliss, DSHS

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