Behavioral Health OrientationHOUSE OF NEW HOPE

REV.4/2014

Welcome to House of New Hope

Welcome, my name is Dr. Jeffrey Greene and I am the Executive Director of House of New Hope. First, a little information about House of New Hope. Founded in 1992, we are a statewide Christian 501(c)3 not-for-profit charitable agency serving Ohio's children, youth, adults and families through programs including Treatment Foster Care, The Danni Hedrick Adoption Services Program, Out-Patient Behavioral Health Services and Developmental Disability waiver services.

We are nationally accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF); licensed by the Ohio Department of Job and Family Services; and certified by the Ohio Department of Developmental Disabilities and the Ohio Department of Mental Health and Addiction Services.

Our Mission

"It is our mission to demonstrate the love and compassion of Jesus Christ by protecting and

enhancing the safety and well-being of persons from all backgrounds and across the continuum of

life through the effective integration of the Christian faith and professional practice in all

agency services."

A Work in Progress Both negative and positive forces are impacting the behavioral healthcare system in Ohio. Among the negatives are our uncertain economy and rising healthcare costs; positive forces include gains in trauma-informed approaches, interdisciplinary collaboration, and use of innovative technologies for quality care. In combination, such forces influence behavioral health resources, business strategies, service delivery approaches, and most importantly, the well-being of consumers and families. Therefore, it is critical that house of New Hope remains actively involved in planning for the future.

I share this with you because CHANGE is a given. Paperwork, processes, procedures, electronic health record systems are but a few of the changes that will impact our industry over time.

We are here to provide you with technical assistance, clinical advice and practical guidance. All you have to do is ask when you are unsure.

Your Support Team

Let me introduce Rachel Young, MSW, LISW-S. Rachel is our Director of Clinical Services. This involves overseeing our Performance & Quality Improvement (PQI) program, as well as our Behavioral Health Services.

She is available to answer clinical and programmatic questions, concerns with our electronic health record, and more.

Email: ryoung@houseofnewhope.org

Even More Support

Let me also introduce Glenn McCleese, MSW, LISW-S. As our Director of Special Populations, Glenn is certainly your point person on clinical issues related to working with developmentally disabled clients. Additionally, he is the co-facilitator of our out-patient behavioral health program and available to answer your clinical and programmatic questions, too.

For independent contractors: you will send your invoices and required documentation to Glenn for approval.

E-mail: gmccleese@houseofnewhope.org

House of New Hope’s Treatment Philosophy

Our Treatment Philosophy Rather than subsuming the entirety of the person, mental health conditions are better understood—even in their most severe form—as disabilities that co-exist with other areas of competence within the context of the person’s life.

Just as we would not assume that someone with a visual, auditory, or mobility impairment was unable to take care of him or herself because he or she could not see, hear, or ambulate unassisted, we need not assume that a person’s mental health condition renders him or her unable or incompetent to be in control of his or her life. As other people with disabilities may require Braille signs, visual indicators of doorbells or ringing telephones, or wheelchairs, people with mental health conditions may require similar social and environmental supports in order to function optimally in community settings.

As a representative of House of New Hope, it is expected that you will integrate the following approaches into your practice.

The Role of the Mental Health Practitioner

What, then, is the most appropriate role for the mental health care practitioner in relation to recovery? Similar to the example above, what the person in recovery is most in need of is information about the nature of his or her difficulties, education about the range of effective interventions available to overcome or compensate for these difficulties, access to opportunities to utilize these interventions in regaining functioning, and supports required in order to be successful in doing so.

Working in collaboration with your client, today’s mental health practitioner assists in evaluating the client’s strengths (the platform from which recovery and growth can occur) and areas of deficiency (the driving force from which the client’s strengths can assist in overcoming), and devising an intervention plan that improves personal and social functioning.

Recovery-Based Approaches to Treatment

In February of 2001 President George W. Bush announced his New Freedom Commission on Mental Health. This commission set out to accomplish six goals. The first two of them were:

1. Americans understand that mental health is essential to overall health and that mental health care is individual and family driven.

2. Their vision statement was, “We envision a future when everyone with a mental illness will recover, a future when mental illnesses can be prevented or cured, a future when mental illnesses are detected early, and a future when everyone with a mental illness at any stage of life has access to effective treatment and supports - essentials for living, working, learning, and participating fully in the community.”

It is the expectation that contractors and providers will demonstrate commitment to the recovery models for adults and the corresponding resiliency model for children/youth throughout all aspects of service development and delivery. These agencies recognize that recovery must be highly individualized and support individual empowerment along with community reintegration and normalization of the life environment. It is the goal that individuals are fully in charge of their lives and recovery includes the individual and family, as appropriate, in decisions from treatment planning to resources planning.

Although regulatory agencies in Ohio support the concept of recovery and resilience, there are still required elements to ensure appropriate documentation of each encounter or claim. Many of these claim structures are built on a medical model of billing (for example, strict adherence to definitions for service codes and what practitioner of the healing arts is allowed to provide which service.) In order to understand the impact of health care reform on clinical documentation, it is important to consider changes in the regulatory environment for the behavioral health field and the evolution of behavioral health from a traditional medical model to a medical model embedded in a recovery-based approach to care. This change has impacted the manner and focus of documentation. Let’s examine some of these concepts and how they affect documentation.

Traditional Medical Model Shifts to Medical Model Embedded in a Recovery-Based Approach

In a traditional medical model some years back, mental health issues were treated only as a disease that needs to be cured or managed. The primary focus of intervention, as is typical in a disease-based model, was on the physical pathology presented. Elimination or reduction of symptoms (where elimination is not possible) was the goal of treatment; a causation and then mitigation approach. Recovery under this model was often not possible as many individuals with mental illness remained symptomatic at least episodically. They were then considered to be chronically ill with expectations lowered and treatment focused on maintenance. In the traditional medical model treatment plans were developed by “experts”- usually licensed mental health professionals who then oversaw the implementation of “their” plans and then evaluated their effectiveness, often without input or sufficient input from the individual or families.

The recovery-based approach had dramatic impact on the traditional medical model. In recovery-based models the individual with a mental illness goes into treatment with the assumption that recovery is the norm and is to be expected. Skill development and access to resources becomes a much greater focus with eliminating the impact of a particular symptom or improving the person’s ability to function as goals of treatment and rehabilitation services. This new model for treatment has evolved beyond the former philosophy of viewing the patient as a diagnosis that needs to be treated.

The recovery-based approach is person centered treatment. The “patient” is viewed as a person who has every right and ability to participate fully in developing their own treatment plan and goals. The person seeking treatment is viewed as a competent individual fully capable of collaborating in their care throughout all phases of treatment such as planning, implementation, and termination of treatment. The therapist increases the individual’s knowledge of mental illness and helps them to become the experts in their own wellness and recovery management. Recovery plans are formulated by the individual with identification of treatment interventions and also the supports and strengths the individual agrees to use in their continuing process of recovery.

The recovery-based approach is person centered treatment. The “patient” is viewed as a person who has every right and ability to participate fully in developing their own treatment plan and goals. The person seeking treatment is viewed as a competent individual fully capable of collaborating in their care throughout all phases of treatment such as planning, implementation, and termination of treatment. The therapist increases the individual’s knowledge of mental illness and helps them to become the experts in their own wellness and recovery management. Recovery plans are formulated by the individual with identification of treatment interventions and also the supports and strengths the individual agrees to use in their continuing process of recovery.

Symptom-Based Shifts to Strengths-Based

In the traditional medical model of treatment, services were based on symptoms presented by the patient that led to a diagnosis based upon those symptoms. The diagnoses were developed by those who, according to the state, had the required education and experience to do so. Treatment was focused on the symptoms the patient presented in much the same way that a medical doctor would focus on alleviating the physical symptoms of their patients. The focus of treatment in mental health was the individual and their intra-psychic processes. The patient’s symptoms were seen as the result of some type of aberrant process in their psyche. The symptoms were the result of a mental “illness” much as a high fever might be the result of an infection. The traditional treatment model was based on symptoms or problems with little, if any, focus or use of the strengths of the individual.

The recovery model emphasizes the individual’s strengths rather than just their symptoms, deficiencies or problems. Being strengths-based begins during the assessment phase of treatment where the individual along with friends, family and the treatment team should begin to develop the list of the individual’s strengths, talents and resources and discuss how they might be used to help build recovery. The development of strengths lists helps focus the individual on the fact that everything is not bad and pushes the provider to incorporate the whole person, not just the problems or symptoms in their assessment and planning activities.

A “strength” is not the absence of a problem. Strengths include resources, support systems, abilities, accomplishments, motivation, likes, physical and mental health, coping skills and personality traits. There is a list of strengths at the end of this chapter. A strengths-based approach should be reflected in the language of the treatment plan and not just the assessment. In a traditional medical model a provider might write for a goal: “The patient will remain medication compliant for three months.” In the recovery models of care, the focus would be on what will happen next. For example, if the individual and their doctor are able to agree on an effective medication regimen that is acceptable in terms of its effects on symptoms as well as side effects what would happen next? Would the individual be able to go back to school, develop a social support network, successfully manage a transition that is upcoming, etc? The person’s life goal for themselves becomes incorporated into the planning process and is used as an outcome measure to focus treatment.

Strengths-based treatment goes well beyond just identifying strengths of the individual. Those strengths must be used in the treatment plan. They are vital elements in how the individual will cope with the barriers to success that he or she faces. Every goal and objective should have at least one corresponding strength that the client can use in accomplishing it.

Because of payer demands that parts of the medical model still be used in recovery-based treatment, it will be important to make sure that any goals or objectives adhere at least partially to medical model outcomes. In the example above, the life goal on the treatment plan might read: “I will go back to school and graduate from college.” However, because the individual might need all sorts of help to go back to college and graduate, most payers expect the mental health system to focus on a goal that delineates our role in the ability of the person to achieve their life goal. In that case, we might write a treatment goal as well. For example, “the individual will be able to manage their symptoms so that they can successfully manage college level educational demands.” In this way we remain focused on the life goal of the individual, but have limited our involvement for payment purposes to helping the individual identify and then eliminate, reduce, cope and manage those symptoms that are creating barriers to their recovery.

Provider as Director Shifts to Provider as Partner

In the Traditional Medical Model, the provider was viewed as the expert in deciding how the symptoms would best be treated. The patient was more of a passive recipient of the treatment methods of the provider. To be sure, the patient presented the material through which the provider worked, but the provider did the interpretation of what was significant and how it should be handled. The provider suggested healthy ways to handle the symptoms the patient brought up and used the therapeutic techniques he or she had been taught to increase the patient’s insight into the root cause of their distress or provided an accepting atmosphere in which the patient could gravitate toward better mental health through the warmth and understanding the provider projected.

In the recovery based approach, the process shifts from a provider driven to an individual driven process. The provider becomes more of a partner and the individual assumes a major responsibility for treatment. Each individual charts their own course to recovery rather than a standard treatment approach based on diagnosis or symptoms. The individual defines the goals rather than the provider. The provider teaches the individual the necessary skills and knowledge to manage their recovery process and helps them identify coping techniques that they are willing and able to use in their recovery. The barriers to success are identified and strategies are developed to deal with these barriers.

Curing Illness Shifts to Managing Illness

In the traditional medical model the focus was on curing the underlying condition. The theory was the symptoms would go away if the underlying condition was “cured”. The provider made the decision as to what the underlying condition was that needed to be treated: the real problem. The alleviation of the symptoms of this underlying problem was merely a step along the way to cure of the causative mental illness.

The recovery-based approach shifts the focus of care from professionally directed management of acute episodes of symptoms to client directed management of long term recovery.

◦ Treatment is seen not as eliminating all symptoms of the mental illness but giving the individual the skills and confidence to manage their condition on a long term basis.

◦ This involves having a treatment plan developed by and for the individual with strategies to promote and maintain health.

◦ Recovery emphasizes the resiliency of the individual and their strengths and abilities to manage their life rather than the professional’s ability to alleviate symptoms.

◦ The provider’s job shifts to helping the individual identify their own resources and how to use them in challenging situations that may arise.

◦ The reliance is more on the individual and less on the professional community.

The effect of this focus on assisting the individual in managing their life is to normalize or destigmatize living with a mental illness. Every individual has to manage their life and work on their life goals taking into consideration the strengths and resources they have. All people face challenges along the way whether they may be physical limitations, financial difficulties or emotional challenges.

Professional Focus Shifts to Social System Focus

In the traditional medical model the professional is emphasized as the expert to cure and manage illness. As treatment has moved into a strengths-based and recovery-oriented system, the individual’s place in the broader social system and the individual’s attributes are emphasized as the keys to treatment. The culture and unique strengths and situation of the individual must be considered and incorporated into their treatment plan. Culture could be defined as the shared values, beliefs and behaviors of certain people who identify themselves as a group perhaps through similar ethnicity, gender, class or other shared characteristics. Culture affects the way people view, respond to and accept treatment. Culture is a two-way street. The culture of the individual effects treatment and the culture of the service provider also effects treatment.

Culturally competent treatment involves an understanding of the way in which various factors such as gender, race, ethnicity, age, disability, language, sexual orientation, religious beliefs, and social class effect treatment. The way in which individuals are approached may vary depending upon these factors. The type of interventions utilized may vary depending upon these factors. Cultural competence, like being strengths-based, begins in the assessment phase of treatment, cultural issues need to be identified in the assessment, and then addressed in the treatment plan

Language Has Meaning Language is important. In a medical model the provider works with a “schizophrenic” while the strength based provider works with a person who has schizophrenia (“person first” language.) The diagnosis does not define the person. In recovery based treatment models, the provider uses the individual’s language as much as possible. Goals are stated in the individual’s own words and operationalized to be observable and measureable. The language of the plan is understandable to all participants. Deficit based language is replaced by strength based language. Promoting recovery advances a different mindset than preventing relapse. “Professional language” can subtly convey unintended messages to the individual leading them to limit their options.

Language AlternativesDeficit-based Language Strength-based, Recovery-oriented

Alternative Language

A schizophrenic, a bipolar, a crack addict, a substance abuser

A person diagnosed with Schizophrenia who experiences delusions or hallucinations. A person diagnosed with bipolar disorder who experiences rapid changes in mood and behavior. A person diagnosed with an addiction to crack cocaine. A person whose substance use interferes with their life.

Suffering from Working to recover from; experiences; living with

High functioning vs. low functioning

A person is able to function well in most activities of daily living, despite the presence of mental health symptoms VS limited or impaired ability to function that interferes with activities of daily living due to mental health symptoms

Acting out Individual prefers to use alternative strategies to deal with emotions (swearing at peers or throwing things at staff)

Deficit-based Language Strength-based, Recovery-oriented Alternative Language

Denial A person who disagrees with diagnosis or that they have a mental illness. A reluctance to acknowledge stigmatizing designations is not unusual.

Resistant Individual is not open to…. Chooses not to…..Has their own ideas about what may be helpful.

Unmotivated Individual is not interested in what a program has to offer; interests and motivating incentives unclear

Weaknesses Areas to address in treatment; possible barriers to change.

Manipulative A person is resourceful; seeking support; or trying to get help.

Dysfunctional A person experiencing challenges in managing the functions of daily life or a particular domain of functioning like family life.

Non-compliance Individual who prefers alternative strategies.

Trauma-Informed Behavioral Healthcare

Trauma is a near universal experience of individuals with behavioral health problems. According to the U.S. Department of Health and Human Services Office on Women’s Health, 55% – 99% of women in substance use treatment and 85% – 95% of women in the public mental health system report a history of trauma, with the abuse most commonly having occurred in childhood. The Adverse Childhood Experiences study conducted by the Centers for Disease Control and Prevention and Kaiser Permanente, is one of the largest investigations ever conducted to assess associations between childhood maltreatment and later-life health and wellbeing. Almost two-thirds of the study participants reported at least one adverse childhood experience of physical or sexual abuse, neglect, or family dysfunction, and more than one of five reported three or more such experiences.

An individual’s experience of trauma impacts every area of human functioning — physical, mental, behavioral, social, spiritual. The ACE Study revealed that the economic costs of untreated trauma-related alcohol and drug abuse alone were estimated at $161 billion in 2000. The human costs are incalculable.

Trauma is shrouded in secrecy and denial and is often ignored. But when we don’t ask about trauma in behavioral healthcare, harm is done or abuse is unintentionally recreated by the use of forced medication, seclusion, or restraints.

The good news is that trauma is treatable — there are many evidence-based models and promising practices designed for specific populations, types of trauma, and behavioral health manifestations.

Addressing trauma is now the expectation, not the exception, in behavioral health systems.

Trauma-specific interventions are designed specifically to address the consequences of trauma in the individual and to facilitate healing. Treatment programs generally recognize the following:

◦ The survivor's need to be respected, informed, connected, and hopeful regarding their own recovery◦ The interrelation between trauma and symptoms of trauma (e.g., substance abuse, eating disorders,

depression, and anxiety)◦ The need to work in a collaborative way with survivors, family and friends of the survivor, and other human

services agencies in a manner that will empower survivors and consumers.

As a therapist representing House of New Hope, there is an expectation that you will implement trauma-informed behavioral healthcare into your practice.

We march to many drummers… When providing out-patient behavioral health care, you are, at a minimum, required to follow the rules and regulations of the following organizations:

Counselor, social Worker and

Marriage and Family Therapist

Board

Medicaid

Ohio Department of Mental Health

and Addiction Services

Professional Ethics and Conduct Professional Codes of Ethics

House of New Hope endorses the Codes of Ethics for the following:

◦ The Ohio Counselor, Social Worker and Marriage and Family Therapist Board;

◦ The American Counseling Association;

◦ The National Association of Social Workers; and any other boards or organizations associated with the legal credentials of an employee

Therapists are encouraged to become familiar with the code of ethics associated with their particular license or certification.

Ethical practices include but are not limited to the following general topics:◦ Competency and misrepresentation

◦ informed consent

◦ Delegation

◦ Confidentiality

◦ Termination

◦ Sexual harassment

◦ Discrimination

◦ Sexual relationships

◦ Conduct with clients

◦ Dual relationships

◦ Impaired practice

◦ Use of assessment and testing instruments

◦ Payment for services

◦ Record keeping

◦ Mandatory reporting

◦ Scope of practice

What is Medicaid? Most of the persons we serve have their behavioral healthcare costs covered by Medicaid.

Medicaid is a public health care program funded by the state and federal governments.

It provides necessary health care coverage to certain limited income individuals.

Ohio government chooses which Medicaid allowable services are to be made available to Ohio citizens. Behavioral health agencies determine which of the available Ohio Medicaid services they desire to be certified to provide. House of New Hope is certified to provide:

◦ Mental Health Assessment Service (OAC 5122-29-04)◦ Behavioral Health Counseling and Therapy Service (OAC 5122-29-03)◦ Community Psychiatric Supportive Treatment (OAC 5122-29-17)

Medicaid and Clinical Documentation

In Ohio, Medicaid funds behavioral healthcare services through the Psychiatric Rehabilitation Option; often known as the “Rehab Option (MRO)”.

The MRO pays for services rather than programs.

Ohio’s Covered services include:◦ Mental Health Assessment service◦ Behavioral Health counseling and Therapy service◦ Community Psychiatric Supportive Treatment service (CPST)

5122-29-03 Behavioral Health Counseling and Therapy Service.

A. Behavioral health counseling and therapy service means interaction with a person served in which the focus is on treatment of the person’s mental illness or emotional disturbance. When the person served is a child or adolescent, the interaction may also be with the family members and/or parent, guardian and significant others when the intended outcome is improved functioning of the child or adolescent and when such interventions are part of the ISP.

B. Behavioral health counseling and therapy service shall consist of a series of time-limited, structured sessions that work toward the attainment of mutually defined goals as identified in the ISP.

C. Behavioral health counseling and therapy service may be provided in the agency or in the natural environment of the person served, and regardless of the location shall be provided in such a way as to ensure privacy.

D. For behavioral health counseling and therapy services for children and adolescents, the agency shall ensure timely collateral contacts with family members, parents or guardian and/or with other agencies or providers providing services to the child/adolescent.

5122-29-04 Mental Health Assessment Service

A. Mental health assessment is a clinical evaluation provided by an eligible individual either at specified times or in response to treatment, or when significant changes occur. It is a process of gathering information to assess client needs and functioning in order to determine appropriate service/treatment based on identification of the presenting problem, evaluation of mental status, and formulation of a diagnostic impression. The outcome of mental health assessment is to determine the need for care, and recommend appropriate services/treatment and/or the need for further assessment. Results of the mental health assessment shall be shared with the client.

B. An initial mental health assessment must be completed prior to the initiation of any mental health services. The only exceptions to this would be the delivery of crisis intervention mental health services or pharmacologic management services as the least restrictive alternative in an emergency situation.

5122-29-17 Community Psychiatric Supportive Treatment (CPST) Service.

A. Community psychiatric supportive treatment (CPST) service ) provides an array of services delivered by community based, mobile individuals or multidisciplinary teams of professionals and trained others. Services address the individualized mental health needs of the client. They are directed towards adults, children, adolescents and families and will vary with respect to hours, type and intensity of services, depending on the changing needs of each individual. The purpose/intent of CPST services is to provide specific, measurable, and individualized services to each person served. CPST services should be focused on the individual’s ability to succeed in the community; to identify and access needed services; and to show improvement in school, work and family and integration and contributions within the community.

Activities of the CPST service shall consist of one or more of the following:

1. Ongoing assessment of needs;

2. Assistance in achieving personal independence in managing basic needs as identified by the individual and/or parent or guardian;

3. Facilitation of further development of daily living skills, if identified by the individual and/or parent or guardian;

4. Coordination of the ISP, including: ◦ Services identified in the ISP; ◦ Assistance with accessing natural support systems in the

community; and ◦ Linkages to formal community service/systems;

5. Symptom monitoring;

6. Coordination and/or assistance in crisis management and stabilization as needed;

7. Advocacy and outreach;

8. As appropriate to the care provided to individuals, and when appropriate, to the family, education and training specific to the individual’s assessed needs, abilities and readiness to learn;

9. Mental health interventions that address symptoms, behaviors, thought processes, etc., that assist an individual in eliminating barriers to seeking or maintaining education and employment; and

10. Activities that increase the individual’s capacity to positively impact his/her own environment.

Meeting our Regulatory Requirements

The federal Centers for Medicare & Medicaid Services (CMS), located within the Department of Health and Human Services (HHS), oversees the Medicaid program guided by federal law and rules.

Ohio is required to comply with these federal laws and regulations by creating state regulations and rules that are placed into the Ohio Administrative Code (OAC). These rules govern both the provision of Medicaid and all of Ohio’s behavioral health care services (mental health and addictions).

OAC 5122-29 and OAC 5122-27 specifies Ohio’s behavioral health service standards and documentation requirements. As a provider, YOU are legally responsible to be compliant with these regulations.

House of New Hope uses a combination of computer-based and web-based forms to meet all documentation requirements.

Medicaid and Rehabilitative Services in Ohio

Rehabilitation services are defined in federal law at 42 CFR 440.130 as:

“any medical or remedial services (provided in a facility, home or other setting) recommended by a physician or other licensed practitioner of the healing arts, within the scope of his/her practice under State law, for the maximum reduction of physical or mental disability and restoration of the individual to the best possible functional level.”

Medicaid Billing The MRO/Rehab Option provides clear guidance for delivering, billing, and documenting services.

Services must be related to a mental health diagnosis that is identified in a mental health assessment, with goals and objectives specified on an individualized service plan (ISP).

Services must be “medically necessary.”

What is Medical Necessity? According to Medicaid, “Medically necessary mental health services” refer to those mental health services, including but not limited to:

◦ Preventive,◦ Diagnostic,◦ Therapeutic,◦ Rehabilitative and◦ Palliative interventions,… provided for the symptoms, diagnosis and treatment of a particular disease or condition.

Only when you have diagnosed a person with a mental disorder following the completion of a mental health assessment, have you met medical necessity for services to begin.

HOWEVER, not all services delivered are medically necessary.

Medicaid asks the question: “Why does it take a mental health professional to deliver the service?”

5101:3-1-01 Medicaid: medical necessity

According to the Ohio Administrative Code:

"Medical necessity" is a fundamental concept underlying the Medicaid program. Physicians, dentists, and limited practitioners render, authorize, or prescribe medical services within the scope of their licensure and based on their professional judgment regarding medical services needed by an individual.

“Medically necessary services" are defined as services that are necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort.

In order to justify the continued provision of mental health services, you must be able to demonstrate through your documentation that the service you are providing the client is medically necessary and that without the specific mental health service that you are providing, “the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort.”

What is Medical Necessity? A medically necessary service must:

(1) Meet generally accepted standards of medical practice;◦ If the client had gone to another practitioner instead of you, would they have received a similar service?

(2) Be appropriate to the illness or injury for which it is performed as to type of service and expected outcome;

(3) Be appropriate to the intensity of service and level of setting;◦ Is the service you are providing more restrictive than another available service that could accomplish the same outcome?

(4) Provide unique, essential, and appropriate information when used for diagnostic purposes;

(5) Be the lowest cost alternative that effectively addresses and treats the medical problem; and

(6) Meet general principles regarding reimbursement for Medicaid covered services found in rule 5101:3-1-02 of the Administrative Code.

Documenting Medical Necessity OAC 5101:3-1-27

“…all Medicaid providers are required to keep such records as are necessary to establish medical necessity, and to fully disclose the basis for the type, extent, and level of the services provided to Medicaid consumers, and to document significant business transactions.

Medicaid providers are required to provide such records and documentation to the Ohio department of job and family services (ODJFS), the secretary of the federal department of health and human services, or the state Medicaid fraud control unit upon request.”

Documentation focuses on the interventions delivered to meet the goals and objectives and the consumer’s progress toward meeting goals and objectives.

Documenting Medical Necessity of Rehabilitation

Service focus is on teaching (cueing, reminding, training or overcoming barriers) not providing for them.

Medical necessity is based on functional criteria.

CPST is not case management. It is a direct clinical service, not a referral or linkage to care.

The Medicaid Goal for Services In all situations, the ultimate goal is to reduce the scope, duration and intensity of medical care to the least intrusive level possible which sustains health.

The Medicaid goal is to deliver and pay for clinically appropriate, Medicaid-covered services that would contribute to the treatment goal(s).

Within the rules, the MRO encourages a focus on recovery and consumer-related services.

The consumer goals and needs will drive the priorities within the treatment plan. Consumers will be reviewing their services and their progress toward goals with providers on a regular basis. The consumer MUST participate and work towards measurable goals with the right amount of provider support.

Consumers MUST participate in the creation of their treatment plans.

Additional Guidance for Behavioral Health

Rules that are incorporated into medical necessity for payment purposes:

The consumer must be able to be an active participant in their treatment; and

The consumer must have sufficient cognitive ability to benefit from the treatment.

Documentation must be clear about the consumer’s participation in treatment:◦ Besides being present during the intervention, what else occurred?◦ Evidence that the plan has been developed with the active participation of the client;◦ Progress notes must document the services that were provided.

Documentation must follow The Golden Thread.

Medical Necessity: The Golden Thread

The Golden Thread

Mental health assessment:Diagnosis

• Symptoms • Functional, skill and

resource deficits

ISPGoals/objectives

• Services (right for diagnosis, right

provider, intensity, duration)

Progress NotesProgress towards

the identified goals and objectives

ISP ReviewsImpact on symptoms – deficits – better or

“not worse” • Services were

provided as planned

Assessment & Diagnosis

Treatment Planning

Progress Evaluation

Evaluation of Plan

The Golden Thread: Mental Health Assessment

The Mental Health Assessment must identify symptoms; behaviors; functional, skill and resource deficits that conspire to create or maintain a condition that requires mental health services without which the client can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort.

The assessment must identify the critical clinical needs of the client based on their presentation and history; and further establishes their ability to engage in and benefit from services. A diagnosis of a mental disorder begins to establish medical necessity.

Mental Health Assessment

Diagnosis

The Golden Thread: ISP With a list of behaviors, deficits (functional, skill and/or resources) AND a diagnosis, you are ready to work collaboratively with the client (parent/guardian and other treatment team members) to design an Individualized Service Plan (ISP) that identifies specific short-term steps/objectives (measurable, observable, attainable) that, with progress, begins to make significant headway toward accomplishing identified overarching goals.

Mental Health Assessment

Diagnosis

Individualized Service Plan

(ISP)

The Golden Thread: Progress Notes

The progress notes must flow from the treatment plan by specifically reflecting the service provided, the consumer’s participation in their treatment, progress towards the identified steps/objectives and overarching goals, and the consumer’s response to treatment.

Medicaid is interested in knowing that they are funding a beneficial and medically necessary service and treatment.

Mental Health

Assessment

Diagnosis

Individualized Service Plan

(ISP)

Progress Notes

The Golden Thread: Annual ISP Review

The progress notes tie to the ISP reviews and assessment updates by providing a picture of behavior/condition change across time and affording the provider and consumer an opportunity to reiterate needs and goals, and establish the continuing need for services.

Mental Health

Assessment

Diagnosis

Individualized Service Plan

(ISP)

Progress Notes

Annual ISP Review

Follow the Golden Thread Based upon your documentation, the Golden Thread should be very easy for a Medicaid auditor to follow. When the Golden thread is difficult to follow, Medicaid may not be able to justify medical necessity.

It is your responsibility to ensure that medical necessity is firmly established and that The Golden Thread is easy to follow.

Difficulty following The Golden Thread

Assessment Deficits◦ Diagnosis poorly supported◦ Symptoms, behaviors and deficits undefined

◦ No baseline against which to determine progress or lack

ISP◦ Goals and objectives unrelated to assessed needs/symptoms/behaviors

and deficits (example: “comply with treatment”)

Progress Notes◦ Documents “conversations” about events or mini-crises◦ Does not assess behavior change, i.e. progress toward a goal or objective◦ Does not spell out specifics of intervention(s) used in session.

In summary, any element done in isolation breaks the Golden Thread and disrupts the logic that should be evident from the documentation of the individual’s treatment. This could include:

◦ Identifying critical clinical issues in the assessment that are not addressed in the ISP.◦ Developing treatment goals and objectives/steps that are not individualized or based on the assessment

or assessment update.◦ Documenting clinical activities in the progress notes that are not driven by the specific goals and

objectives identified in the ISP.◦ Failing to update the ISP when issues are resolved or new issues are identified.◦ Failing to change the treatment strategy and goals when the individual is not progressing.

The Penalty for Failing to Establish Medical Necessity

As you have learned, medical necessity establishes the basis for Medicaid reimbursement. Medical necessity is established through The Golden Thread:

◦ A diagnosis based upon a thorough mental health assessment.

◦ An ISP that relates to the needs, behaviors, conditions, and deficits established in the assessment and highlighted through a diagnosis.

◦ Progress notes that continue to establish a medical necessity for the service, along with the consumer’s participation and progress toward ISP objectives and goals.

◦ An annual review of the ISP (and mental health re-assessment if necessary) that evaluates progress or lack, thereof, and reinforces the current plan or redesigns the plan as the case may be.

The penalty for failing to firmly establish medical necessity is financial PAY BACK of ALL Medicaid payments from Medicaid to the provider.

Before any service is billed to Medicaid, your documentation will be reviewed by our supervisory clinical staff for appropriate medical necessity language.

No invoices for services will be paid to a provider who has failed to establish medical necessity through required documentation.

Medicaid and Medicare Fraud & Errors

Fraud:

Fraud is knowingly and willfully attempting to falsely obtain money from any health care benefit program. Fraud is distinguished from abuse in that there is clear evidence that the acts were committed knowingly, willfully and intentionally or with reckless disregard. Fraud is an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It Includes any act that constitutes fraud under applicable Federal or State law (42 CFR 455.2).

Errors:

Improper Payments result when an inaccurate, incomplete, or non-compliant claim or encounter is submitted to the payer. Improper payments can be the result of fraudulent or abusive activities but many are simply the results of errors or mistakes. Unfortunately an auditor is generally not concerned with the reason for the improper payment. They will want a payback and depending on the numbers of errors may assess penalties or further investigate. In cases where they find a pattern of inaccuracies on the part of the organization or a clinician they may assess individual penalties.

Here’s a Little Secret

One way to check that you have successfully completed The Golden Thread and established medical necessity is to look at your documentation in reverse.

• Does your last Progress Note specifically address an objective/step and/or goal listed on the ISP?

• Would the objectives/steps and overarching goal(s) listed on the ISP, if successfully completed by the client, alter their diagnosis or positively impact their morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort.

• Does the mental health assessment identify enough behavior or symptoms to fully justify the diagnosis you have given the client.

Rules Governing your License All providers of behavioral health services for House of New Hope are licensed by the Ohio Counselor, Social Worker, and Marriage and Family Therapist Board. OAC 4757-5-01 sets forth the “Standards of ethical practice and professional conduct” that governs your behavior as a behavioral healthcare professional.

Your position as an employee or independent contractor for House of New Hope provides you absolutely no protection should you violate the rules that govern your license.

You should be very familiar with the OAC rules regarding:◦ Informed consent◦ Termination of services◦ HIPAA and confidentiality◦ Multiple relationships◦ Record keeping and documentation◦ Scope of practice

The Basics of Clinical Documentation

There are two main components to most Behavioral Health documents:1. Documentation of medical necessity and The Golden Thread

2. Signature dates and mandated deadlines.

Let’s start with some small technicalities:3. All entries must be legible

4. If not typed, use only ink (blue or black)

5. Every page must have some form of client identification

6. Never use the name of other clients in the record (may use initials)

7. Do not “rubber stamp” or “cut and paste” your record entries; tailor wording to the changing needs of your client

8. Correcting errors: Do not use correction tape/fluid, scribble over, etc. Instead, draw a single line through the error & initial, then enter correct material.

a) Only original authors may make alterations.

b) Reviewers and supervisors may not edit original authors but may supply an addendum with dated signature.

All payers require that any service that is billed or encountered be backed up by sufficient and legible documentation in the individual’s health record. Documentation must describe a service the payer will pay for, must demonstrate that the service was medically necessary, and must meet the payer’s requirements for all of the information needed to document the service, for example the credentials of the provider and the location of the service.

The only way an auditor can evaluate the quality and accuracy of the service rendered is by what was written and billed/encountered to support the service.

Excellent clinical work will not be known to an auditor unless he or she can read the information that demonstrates that excellence.

The Intake ProcessCompleted To Initiate Referral and Verified within 1 Business Day:

New Member Enrollment Form completed/UCI Request (fill in all * items) MACSIS Residency Verification (Fill in adult or child section with signatures and date) MACSIS Enrollment and Disclosure Form (Fill in completely and HONH Agency Staff signature & date)

Client is then added into FreeMed Completed Prior to First Appointment/At First Appointment:

MACSIS Privacy Notice (client keeps copy & Staff signs form on use and disclosure) Financial Information Form (Fill in completely by client and/or parent/caregiver/guardian) Assignment of Benefits Form (Fill in completely by client and/or parent/caregiver/guardian) Consent for CPST Services (effective date must be prior to any services provided) Consent for Behavioral Counseling (effective date must be prior to any services provided) Consent for Diagnostic Assessment (effective date must be prior to any services provided) Privacy Practices HIPPA Receipt (effective date must be prior to any services provided) Client Rights & Grievance Receipt (effective date must be prior to any services provided) Authorization for Release of Information (as needed) 6-Month follow up survey consent form (competed by client, guardian/caregiver/parent) Mental Health Consumer Outcome Tracking Sheet (Completed by HONH & turned into QI dept) Mental Health Recovery Measure (adults) Outcomes Consent Form (all clients) Strengths and Difficulties Questionnaire (by age group for children) Client receives a Copy of Mental Health Orientation Booklet and HONH Privacy

Practices in packet.

During the First Session

Completed Following the First Appointment

Completed Following First Appointment: Diagnostic Assessment SOQIC Form Mental Status Exam Lethality Assessment (if needed) Addition of Diagnoses in FreeMed (must be done prior to completing FreeMed Note) FreeMed Assessment Note (sent to St. Louisville with your first invoice)

Completed for Each Session

Completed For Each Session: Progress Note (within 24 hours of appointment)

Completed Within 30 Days or 5 Sessions (whichever is longer)

Completed as Needed

Completed Semi-Annually

Completed Semi-Annually Outcome Form with Tracking Sheet

Submitted with Invoice

Completed Annually

Completed Annually ISP with Guardian signature Outcome Form Client Rights Form Privacy Practice

Submitted with invoice to allow for payment of services

Completed at Transfer/Discharge

Completed At Transfer/Discharge Transfer/Discharge Summary with Copy given to Client FreeMed Progress Note

Submitted with invoice to allow for payment of services

Let’s Talk About the Business of Behavioral Healthcare

Myths About Nonprofits While nonprofits are all around us, sometimes we find that there are some common misconceptions about what nonprofits are and what they do. Detailed here are some of the more common myths about the sector.

Myth: Nonprofits can’t earn a profit

Reality: Nonprofits can make a profit; however, a nonprofit organization cannot distribute its profits to any private individual. This is because charitable nonprofits are formed to benefit public, not private, interests.

Myth: Most nonprofits are large and have many resources

Reality: In fact, most nonprofits are small in both budget size and numbers of employees. While large national nonprofits like the Red Cross have high visibility, such organizations are not representative of the community as a whole. In 2010, 82.5% of all reporting public charities had annual revenue of under one million dollars.

At the end of the day, you have a fiduciary relationship with your client. If you are or have been squeamish about discussing issues of payment with your clients, it is now time to get over it!

As a representative of House of New Hope, it is your responsibility to ensure that the cost of your services are appropriately reimbursed by a payer… Medicaid, Medicare, private insurance or self-pay. Without this reimbursement, House of New Hope can not afford to pay you for your services and good works.

Billing House of New Hope bills all third party payors for you. We pay you.

While most of us sought a career in counseling and/or social work in order to make a meaningful difference in the lives of children, youth, adults and families, with few exceptions, these endeavors cannot occur without sufficient financial backing to support programs and initiatives.

In other words, you don’t get paid for providing services unless House of New Hope gets paid.

As a representative of House of New Hope, you are responsible to:◦ Ensure that the client is able to cover the cost of their care◦ Ensure that all required financial documentation has been complete prior to the onset of service

provision◦ Ensure that all required clinical documentation is completed in a timely manner and written to “medical

necessity” specifications◦ Know what your client’s insurance status is with each visit, such as if their insurance has changed

Payor of Last Resort If third party liability exists (insurance, Medicare), then Medicaid is always the payor of last resort. This simply means that Medicaid always pays last where other insurance is present.

Recipients are required to keep Medicaid informed of any health insurance information.

As House of New Hope is responsible for notifying Medicaid of third party insurance they find out about as well as informing Medicaid of any third party payments they receive on behalf of the recipient, YOU must always have a copy of a valid Medicaid card in the client record.

YOU are always responsible for assuring that the client has an approved method to cover the cost of your services.

Your Invoice for Services Provided

If you are an independent contractor for House of New hope, you will be required to submit an invoice for services no more than once per month. Checks will be processed within 30 days of receipt.

The invoice must contain the following information:◦ Your full name and credentials◦ Your address, city, state and zip◦ Your telephone number◦ By client name:

◦ The date of each service being invoiced◦ A description of the mental health service provided (mental health assessment, individual counseling, CPST)◦ Units of Service ◦ Payor Type (Medicaid, Molina, CareSource, Anthem BC/BS, Self-Pay, etc.)

All documentation associated with each invoiced service being billed.

Units of Service Most payors will not reimburse for services provided less than 8 minutes. As a result, all invoiced services must be for a unit of service that exceeds 8 or more minutes.

Units of Service should be reported as follows:Services provided are

more thanServices provided are less

thanProviders will bill

8 minutes 23 minutes 1 unit

22 minutes 38 minutes 2 units

37 minutes 53 minutes 3 units

52 minutes 68 minutes 4 units

67 minutes 83 minutes 5 units

82 minutes 98 minutes 6 units

Additional units can be determined by adding 15 minutes to each column of the first two columns.

Number of Allowable Units of Service

As most of behavioral healthcare financing is moving to a managed care model, costs are controlled by a process of pre-authorization. According to OAC 5101:3-27-02:

Mental health assessment services as defined in rule 5122-29-04 of the Administrative Code. ◦ A maximum of four hours of mental health assessment services are allowed per twelve month period.

In accordance with the "Healthchek" benefit, children up to the age of twenty-one may receive services beyond established limits when medically necessary.

Behavioral health counseling and therapy services as defined in rule 5122-29-03 of the Administrative Code.

◦ A combined maximum of fifty-two hours of individual and group behavioral health counseling and therapy services are allowed per twelve month period. In accordance with the requirements of "Healthchek" (Ohio's early periodic screening, diagnosis, and treatment (EPSDT) benefit), children up to the age of twenty-one may receive services beyond established limits when medically necessary.

Community psychiatric supportive treatment (CPST) services as defined in rule 5122-29-17 of the Administrative Code and meet the following requirements:

◦ All CPST services provided in social, recreational, vocational, or educational settings are allowable only if they are documented mental health service interventions addressing the specific individualized mental health treatment needs as identified in the ISP of the person served.

◦ A billable unit of service for CPST service may include either face-to-face or telephone contacts between the mental health professional and the client or an individual essential to the mental health treatment of the client.

◦ A combined maximum of one-hundred and four hours of individual and group CPST services are allowed per twelve month period. In accordance with the "Healthchek" benefit, children up to age of twenty-one may receive services beyond established limits when medically necessary and approved through the prior authorization process. Adults may receive services beyond established limits when medically necessary and approved through the prior authorization process.

◦ CPST services are not covered under this rule when provided to an adult or child in a hospital setting, except for the purpose of coordinating admission to the inpatient hospital or facilitating discharge to the community following inpatient treatment for an acute episode of care.

Authorizing Services Generally, most services do not require authorization. However, when we are close to reaching the service limits, we need to follow a process to extend the limits, if it is medically necessary to do so.

House Bill 153 listed some exemptions from prior-authorization for an extension of CPST services. These include:

◦ Kids under 21 who are:◦ In the temporary custody or permanent custody of a public children services agency or private child placing agency or is in a planned permanent living

arrangement◦ Placed in the protective supervision by a juvenile court◦ Committed to the Department of Youth Services◦ An alleged or adjudicated delinquent or unruly child receiving services under the Felony Delinquent Care and Custody program operated under section

5139.43 of the Revised Code

For these children, we can use what is called a modifier to bypass prior-authorization.

For other services for children (Assessment and Counseling, a soft modifier, called the “SC” modifier can be used to bypass the limits when medically necessary to do so.

For adults, there is no option to obtain more services

How to Pre-Authorize Services and Get Extensions

Procedure:

Ohio uses Permedion for prior-authorization of services This typically affects CPST services the most

In order for this to happen, Permedion requires clinical documentation be completed and a completed ISP

The link to access the authorization form is: http://hmspermedion.com/oh-medicaid-mental-health-addiction-services/cpst-prior-authorization/

This form should be faxed to Permedion

They will respond within 3 working days

Some will be referred for physician review

When denied, there is an appeals process that Permedion follows

Where to Send Invoices and Documentation

Procedure:

Invoices and documentation will be sent to:

Glenn McCleese, LISW-SDirector of Special PopulationsHouse of New Hope, 8135 Mount Vernon Road, St. Louisville, OH 43071

Glenn will verify that all required documentation is there, contact the therapist if there is missing documentation, and approve any portions of the invoice for which there is documentation to support the billed service.

Initial Referrals for Behavioral Healthcare Services

It is very likely that consumers, guardians and agencies will contact you directly with a referral for behavioral healthcare.

Procedure:◦ Send the financial intake packet (UCI Request, MACSIS Residency Verification, Financial Information Form)◦ Either have them send the forms directly to Director of Clinical Services at House of New Hope or if they give

them to you forward them on to House of New Hope◦ Once received, benefits will be verified within one business day◦ The therapist will be updated regarding the insurance status of the client and if the client is approved to

initiate services. The therapist is responsible for following up with the client and/or guardian on the status.◦ Once approved, the therapist can schedule the first appointment. They must ensure that there will be

someone there to sign the needed consents at the first appointment, such as the guardian, or have them completed prior to the first appointment.

◦ The consents must be sent with the first invoice and the Diagnostic Assessment for payment of invoice. Services will not be billed or paid to the therapist without the required consents.

Referral Summary

A client for mental health services CANNOT be started without prior approval from House of New Hope. If a client is started without prior approval and/or without all of the required consents completed, you as the Therapist WILL NOT be paid for the service provided. You will not be paid until all necessary paperwork is received and then only from that date forward.

By seeing a client without approval and consents, you as the Therapist are placing yourself at risk for ethical and/or legal violations.

Closing and Re-starting Cases Closing a Case:

◦ Procedure:◦ For a client who does not show for multiple appointments

or does not continue with services, the therapist must document reasonable attempts to contact the person to reschedule

◦ Once a client has not maintained contact with the therapist for 30 days and the therapist has documented reasonable attempts to maintain contact, the therapist can proceed with closing out the case.

◦ They should at this time complete a Transfer/Discharge Summary and send this with their regular invoice to House of New Hope.

◦ House of New Hope will proceed upon receipt of the Transfer/Discharge Summary to close out the chart.

Re-Opening a Closed Case◦ Procedure

◦ If a client has been seen within the last 365 days of requesting to re-open a file, the original consents received can be used.

◦ If a client has not been seen within the last 365 days, then the intake process must be restarted.

◦ Once it is verified if new consents are needed and they are obtained if needed, the therapist can proceed with reinstating services. For clients who start the process as a new client, a new Diagnostic Assessment must be completed along with a Diagnostic Assessment progress note.

◦ If a client is able to restart without completing the intake packet and the prior consents are viable, the therapist should complete a Diagnostic Assessment Update and Diagnostic Assessment progress note.

◦ In both situations, a new ISP must be developed.

Documenting Changes Demographic

◦ When your client has a change in their demographic status, a new demographic sheet must be completed and submitted with your next invoice

◦ If the information is significant enough to need to update the Diagnostic Assessment then fill out the Diagnostic Assessment Update form

Diagnostic◦ When your client has a change in diagnosis, either what diagnosis is primary, an addition or deletion of a

diagnosis, or a change of a diagnosis, there are several forms of different that must be completed and updated

◦ Change the diagnosis in the electronic medical record system. Do not delete a diagnosis but make it inactive

◦ For the appointment complete a diagnostic assessment update SOQIC form for the date of service◦ For the appointment complete an assessment progress note◦ All of this must be sent with your next invoice for payment of services

HIPAA & Confidentiality Most of us feel that our health and medical information is private and should be protected, and we want to know who has this information. Now, federal law gives all of us rights over our health information and sets rules and limits on who can look at and receive our health information. The children and families that are served by all departments of House of New Hope (with the exception of foster care) are protected by PL104-191, the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

The Privacy Rule ensures a national floor of privacy protections for patients by limiting the ways that health plans, pharmacies, hospitals and other covered entities can use patients' personal medical information. The regulations protect medical records and other individually identifiable health information, whether it is on paper, in computers or communicated orally.

Key provisions of these standards include:

Access to Medical Records. Patients generally should be able to see and obtain copies of their medical records and request corrections if they identify errors and mistakes. Health plans, doctors, hospitals, clinics, nursing homes and other covered entities generally should provide access these records within 30 days and may charge patients for the cost of copying and sending the records.

Notice of Privacy Practices. Covered health plans, doctors and other health care providers must provide a notice to their patients how they may use personal medical information and their rights under the new privacy regulation. Doctors, hospitals and other direct-care providers generally will provide the notice on the patient's first visit and anytime thereafter upon request. Patients generally will be asked to sign, initial or otherwise acknowledge that they received this notice. Health plans generally must mail the notice to their enrollees upon initial enrollment and again if the notice changes significantly. Patients also may ask covered entities to restrict the use or disclosure of their information beyond the practices included in the notice, but the covered entities would not have to agree to the changes.

Limits on Use of Personal Medical Information. The Privacy Rule sets limits on how health plans and covered providers may use individually identifiable health information. To promote the best quality care for patients, the rule does not restrict the ability of doctors, nurses and other providers to share information needed to treat their patients. In other situations, though, personal health information generally may not be used for purposes not related to health care, and covered entities may use or share only the minimum amount of protected information needed for a particular purpose. In addition, patients would have to sign a specific authorization before a covered entity could release their medical information to a life insurer, a bank, a marketing firm or another outside entity for purposes not related to their health care.

Prohibition on Marketing. The Privacy Rule sets restrictions and limits on the use of patient information for marketing purposes. Pharmacies, health plans and other covered entities must first obtain an individual's specific authorization before disclosing their patient information for marketing. At the same time, the rule permits doctors and other covered entities to communicate freely with patients about treatment options and other health-related information, including disease-management programs.

Stronger State Laws. The federal privacy standards do not affect state laws that provide additional privacy protections for patients. The confidentiality protections are cumulative; the Privacy Rule sets a national "floor" of privacy standards that protect all Americans, and any state law providing additional protections continues to apply. When a state law requires a certain disclosure -- such as reporting an infectious disease outbreak to the public health authorities -- the federal privacy regulations does not preempt the state law.

Confidential Communications. Under the Privacy Rule, patients can request that their doctors, health plans and other covered entities take reasonable steps to ensure that their communications with the patient are confidential. For example, a patient could ask a doctor to call his or her office rather than home, and the doctor's office should comply with that request if it can be reasonably accommodated.

Mandatory Reporting & Explicit Threat

Any workforce member receiving information that a child, adult (over the age of 60), or person diagnosed with developmental disabilities is being abused, neglected, and/or exploited by any person shall make a report to the local authority authorized in Ohio law to receive such a report. The workforce member shall consult with their Departmental Director about the suspected abuse, neglect, and/or exploitation immediately upon receipt of such information and initiate a report to the authorized agency.

Pursuant to ORC 2305.51, if a mental health client/patient has communicated an explicit threat of inflicting imminent and serious physical harm to or causing the death of one or more clearly identifiable potential victims, and the mental health professional has reason to believe the client/patient has the intent and ability to carry out the threat, the mental health professional has a duty to predict, warn of and/or take precautions to provide protection from the violent behavior of the mental health client/patient. The workforce member shall consult with the Executive Director about the explicit threat immediately upon receipt of such information and initiate appropriate action.

Reporting Incidents to ODMHAS ODMHAS changed the rule in 2012 to adjust what items must be reported to ODMH. A good reference can be found at http://mha.ohio.gov/Portals/0/assets/Regulation/LicensureAndCertification/webinar-odmh-incident-reporting-slides.pdf.

Some of the key points to reference include topics that require reporting through the incident protocol:

◦ Abuse or neglect by staff◦ Death of a client◦ Homicide or suspected homicide by a client◦ Bodily injury through physical assault or restraint of a client◦ Sexual assault of a client

If you receive one of these situations please contact your supervisor

Testifying in Custody Issues The CSWMFT board’s investigation department receives almost 50% of its complaints referencing custody dispute issues.

You may find yourself in a situation where one or the other of the child’s parents (or their attorney), requests or subpoenas you to testify regarding a custody recommendation.

It is imperative that you acquaint yourself with OAC 4757-06-01 - Reports prepared for court review including custody, visitation and guardianship concerns.

The board has disciplined licensees who have stepped outside of their role in custody matters. Remember, any time you find yourself in this situation and are unsure as to how to proceed, seek supervision, consult with peers, seek legal advice from an attorney familiar with your professional practice, and as always feel free to contact the board.

Subpoenas, Search Warrants & Investigations

Per House of New Hope Policy HR 070:

Procedure:

1. Staff must notify the Executive Director if they receive a subpoena, search warrant, or are under investigation by an outside legal entity, or other legal action.

2. Staff shall immediately share and discuss the content of the legal document/action with their immediate supervisor in order to determine their appropriate, agency-approved response.

3. Only a subpoena signed by a judge will be cause for the release of consumer records.

4. All activities related to a staff member’s participation in a legal procedure(s) identified above, will document their activity/involvement as it pertains to the specific incident.

5. There is to be no shredding or other such destruction of records in question.

Referrals for Psychiatric Support Working within community mental health, you will often find yourself in a position where a client could benefit from other services. Depending on the area the client comes from will dictate your involvement in referrals.

◦ Foster Care: these clients have a case manager who will facilitate all referrals, such as a referral for psychiatric care. If a release is obtained, speak with the case manager and have them process the referral as they are skilled in navigating the child welfare system.

◦ Developmental Disabilities: these clients have staff and Guardians that facilitate the referral for psychiatric care of other services. Provide the information to staff and/or Guardians and they will navigate obtaining the referral.

◦ Community Client: these clients, both adults and children, often do not have the contacts to navigate the referral. Provide the client and/or Guardian the information and have them process the referral. You should provide support throughout this process.

Conclusion

This training and our associated clinical manual is designed to provide you with some assistance as you go about the business of providing behavioral healthcare to Ohio’s children, youth, adults and families. We are here to assist. Do not hesitate to contact Rachel, Glenn or me.

You carry a considerable amount of legal and ethical responsibility as a licensed behavioral healthcare professional. Be sure to take the time to “sharpen your saw.” What does it mean to Sharpen the Saw? It is simply an analogy used by Stephen Covey in his book The 7 Habits of Highly Effective People. You are the saw, and so sharpening the saw is about improving yourself.

We are looking forward to a mutually satisfying relationship. Do not hesitate to contact me with questions, concerns or creative ideas.

If I had eight hours to chop down a tree, I'd spend six sharpening my axe. -- Abraham Lincoln

Jeff

QUIZ & EVALUATION Please complete the attached quiz, including using the attached documentation. Once you are done please complete the evaluation form.