1. Crisis Services Redesign Implementation Overview for LMHA’s Presenter: Mike Maples, Director MHSA

2. 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. Overview

3. 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. Purpose of Redesign

4. 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 Goals of Crisis Redesign

5. This committee was formed with representation from: The recommendations from this group are guiding the course for Crisis Redesign now in it’s Implementation Phase. Crisis Services Redesign Committee  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

6.  REQUESTED: DSHS requested $82 million from the 80 th 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

7.  $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. Crisis Services Funding, cont.

8.  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 Allocation of Funds

9.  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 Equity

10.  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. Proportional

11.  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 Community Incentive

12.  $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 Competency Restoration Funds

13.  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 State Expenditures

14. Crisis Services Standards Presenter: Jennifer Edwards, DSHS Community MHSA Program Services Section

15. 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 Crisis Services Standards

16.  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 Initial Crisis Services: Hotline

17.  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

18.  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.

19.  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 Crisis Hotline Training, cont.

20. Mobile Crisis Outreach Teams provide a combination of crisis services including emergency care, urgent care, and crisis follow- up and relapse prevention to the child, adolescent, or adult in the community. Initial Crisis Services: Mobile Crisis Outreach Teams

21. 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

22.  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 LMHA- designated “peak hours” totaling 56 hours per week  MCOT capability is maintained throughout the Local Service Area (LSA) 24/7 Mobile Crisis Outreach Teams

23.  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

24.  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 Mobile Crisis Outreach Teams

25. 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” Roll-out of Crisis Redesign

26.  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 Services

27. 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) Enhanced Crisis Services

28.  Screening and Assessment Timeframes: 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  Location: 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

29.  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. Crisis Outpatient Services

30.  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

31. 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

32. 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

33. 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

34. 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

35. 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. Extended Observation Services

36.  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 Stabilization Units (CSU)

37. 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

38. 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

39. 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

40. 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, self- administration of medication capability, vital signs, pain, and danger to self or others. Crisis Residential

41. 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

42. 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

43. 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 Residential

44. 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

45. 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

46. 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 facility- based crisis respite units that includes assigned personnel and scheduled activities. Crisis Respite

47. 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

48. 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. Crisis Respite

49.  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)

50.  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)

51. 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)

52.  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)

53.  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)

54.  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)

55.  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. Psychiatric Emergency Service Centers (PESCs)

56. Local Crisis Service Plans Presenters: Chris Dickinson and Dorcas Washburn Community MHSA Program Services Section

57. 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

58. Local Crisis Planning Community stakeholders are a vital part of the local planning process and will be key in successful implementation of crisis services.

59. 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)

60.  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

61. 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

62. 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

63.  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

64.  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 Local Crisis Planning

65. 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 Local Crisis Planning

66. LBB & Contract Performance Presenters: Chris Dickinson and Karen Ruggiero Community MHSA Program Services Section

67. 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 LBB and Contract Performance

68.  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

69.  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

70.  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

71.  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. Contract Performance Measures

72. Crisis Changes to Report III Presenters: Natalie Cloudy Chris Dickinson and Rod Swan Community MHSA Contractor Services Section

73. Line 759 Crisis Services To include all new crisis funding used for crisis services New Line – Crisis Services

74. B.2.3 New Crisis Services To report new Crisis dollars only New Strategy – Crisis Services

75.  Crisis Residential/Inpatient  Crisis Outpatient  Crisis Screening and Eligibility  Crisis Other Crisis Services – Sub-strategies

77.  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

79. A Mapping Document is in development to map Encounter Codes, Procedure codes, and Authority Functions to Report III Sub- strategies. New Report III Crosswalk

80.  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

81. 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: Christopher.Dickinson@dshs.state.tx.us FY08 MH Service Array Changes

82. 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

83. 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

84.  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

85.  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

86. 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

87.  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

88.  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

89.  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

90.  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

91.  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. FY08 MH Service Array Changes Crisis Services

92. UM Guidelines for SP0 & 5 Presenters: Molly Lopez Vicki Belinoski and Perry Young Community MHSA Program Services Section

93. Utilization Management  Utilization Management Guidelines Children’s Services Crisis Services: Package 0 Crisis Follow-up Services: Package 5

94. 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

95. 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

96. 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

97. 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

98. 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

99. 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

100. 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

101. 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 0

102. 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

103. 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

104. 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

105. 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

106. 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 Children’s Service Package 5

107. Utilization Management  Utilization Management Guidelines Adult Services Crisis Services: Package 0 Crisis Follow-up Services: Package 5

108. 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

109. 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

110. 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

111. 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

112. 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

113. 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

114. 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

115. Provider Qualifications, cont. Extended Observation: Trained paraprofessional (Behavioral Health Technician) Crisis Residential Services: QMHP-CS Crisis Transportation: No restrictions Adult Service Package 0

116. 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 time- limited (up to 30 days) brief, solution-focused interventions. Adult Service Package 5

117. 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 In- home Crisis Flexible Benefits *See UM guidelines grid for expected average utilization

118. 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

119. 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

120. Admission Criteria Special Consideration Medicaid recipients may not be underserved due to resource limitation. Adult Service Package 5

121. 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

122. 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 Adult Service Package 5

123. Special Projects Presenter: Lauren Lacefield-Lewis Community MHSA Program Services Section

124.  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

125.  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 Of the 30% Community Investment Incentive Funding Investment Incentive Funding

126. 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

127. Project Selection DSHS will evaluate all competing requests for funding to ensure best value for the use of state funds across the system. Investment Incentive Funding

128.  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. Psychiatric Emergency Services Center

129.  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. Jail & State Hospital Diversion Project

130.  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. Outpatient Competency Restoration

131.  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

132.  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 Timelines

133. 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