Mental Hlth TF Report with Priorities

North Carolina Medical Society Mental Health Task Force Report July 18, 2009 MENTAL HEALTH TASK FORCE Palmer Edwards, MD, Chair 1The Mental Health Task Force provides the following information to the NCMS 2Board of Directors: 4North Carolina Mental Health System Reform – Key Priorities 6BACKGROUND: The NCMS Mental Health Task Force composed of member 7physicians of various specialties, specialty society representatives, and other 8members of the mental health, developmental disabilities, and substance 9abuse treatment community met on March 27, 2009, and June 5, 2009, at 10NCMS Headquarters in Raleigh These meetings included background 11information concerning new DHHS leadership, current efforts to address 12mental health reform, and DHHS requests for NCMS input and 13recommendations concerning specific mental health reform issues The task 14force members present engaged in extensive discussions at each meeting 15generating the following findings and recommendations concerning the top 16priorities that need to be immediately addressed in the statewide mental 17health reform process and issues for ongoing consideration 18 19ITEM 1: The Mental Health Task Force feels the following six issues should be 20key priorities in mental health system reform 21 221 Efforts to increase the number of state-funded 23 community/local psychiatric 24inpatient beds should be continued and enhanced 25 26 Increasing the number of available community/local psychiatric 27inpatient beds will lessen the strain on local emergency rooms monitoring 28and holding patients prior to transfer to one of the four state psychiatric 29hospitals In addition, this increased local psychiatric bed capacity will allow 30more patients to be treated in their own communities and save expensive 31state beds for more severely ill patients who require longer duration 32hospitalizations 33 342 Psychiatric “clinical homes” should be established for selected 35 populations of 36psychiatric patients (see Addendum A for detailed description of “clinical 37 home”) 38 1 Psychiatric “clinical homes” are necessary for persons with 2schizophrenia, severe bipolar disorder, severe personality disorders and 3other diagnoses In addition to providing basic outpatient care, crisis 4evaluation and stabilization are key features Participating professionals in 5“clinical homes” include psychiatrists, nurses, social workers, case managers 6and others Current workforce stability problems may improve if the most 7severe patients can be treated in the most effective and comprehensive 8manner 10 Privatization that has occurred due to mental health reform does not 11consistently provide fundamental services needed by the severely and 12persistently mentally ill Such fundamental services are needed for optimal 13care, to promote compliance with treatments, and to prevent 14decompensation and subsequent overuse of emergency departments and 15inpatient beds A mixed system of state, local management entity (LME), 16and private agency operated clinical homes should be considered 17 183 The Local Management Entity (LME) geographic catchment 19areas should be similar to the Community Care of North Carolina 20(CCNC) network coverage areas 21 22 There are currently twenty-four LMEs statewide being operated at 23various degrees of efficiency A smaller number of LMEs will accomplish the 24same purpose as the current number The resulting substantial 25administrative cost savings would increase available funding for patient care 26The LMEs could easily overlap with the fourteen CCNC networks which would 27promote further integration of primary and mental health care This 28integration would broaden and enhance the available mental health care 29 304 While current LME accountability standards need to be 31reconsidered, paperwork and monitoring burdens that not affect 32treatment outcomes should be reduced 33 34 Both LME administrators and medical directors must perform excessive 35monitoring of services, but often with no clear, useful purpose or relationship 36to treatment outcomes The lack of Utilization Management/Utilization 37Review standardization adversely affects DHHS’s efforts to ensure accurate 38measurements of LME quality 39 40 The ten page Person-Centered Plan should be shortened and 41extensively revised to focus on current treatment needs and consolidation of 42the scattered sections that physicians need to reference In addition, the 43issue of when it is appropriate for primary care physicians versus having 44another professional providing care to sign these mental health focused 45forms should be revisited 46 2 Due to its length and format, both primary care physicians and 2psychiatrists often fail to fully utilize or even read the Person-Centered Plan 3This is despite both groups of physicians being expected to sign and take 4responsibility for the Person-Centered Plan’s content which contains 5potentially useful clinical information 75 Clinical care should be driven by evidenced-based practices 8and physician leadership, similar to the treatment system and 9philosophy of the Community Care of North Carolina (CCNC) 10networks 11 12 Privatization of the mental health care system has resulted in 13widespread substandard and fragmented care with unstable work 14environments for physicians and other clinicians This is due in part to for15profit agencies developing treatment methods based on their broader need 16to achieve financial viability In some situations, it may be necessary to limit 17profits made by proprietary companies in this era of shrinking state 18revenues 19 206 DHHS should apply for a statewide Medicaid waiver as 21currently exists in the Piedmont Behavioral Health system 22 23 A statewide Medicaid waiver will provide all LMEs with greater control 24of their provider networks This would be in sharp contrast to the currently 25mandated “any willing qualified provider” system which results in large 26networks filled with providers of undemonstrated quality and experience 27Currently, LMEs are unable to effectively manage networks by elimination of 28poor quality providers A waiver would allow LMEs to develop relationships 29with only the best quality and most efficient providers 30 31ITEM 2: Following extensive deliberations, the Mental Health Task Force has 32formulated the following responses and recommendations addressing several 33mental health reform issues as requested by the Department of Health and 34Human Services leadership 35 36Question 1: What are components of a mental health system that 37includes acute and outpatient services? 38 39 There are several major components of a mental health system that 40includes acute and outpatient services Most importantly, there must be 41easy access to the treatment system and providers for patients with specific 42problems It should be the rule, not the exception, that assigned first 43responders answer phones and respond quickly when called upon by 44patients In urgent situations, patients and providers should have fast access 45to mobile crisis teams to intervene in mental health emergencies and 46prevent emergency room visits State involuntary commitment laws need comprehensive revision 3concerning clinical and non-clinical issues These laws need to be expanded 4to allow for involuntary commitment utilizing telepsychiatry in appropriate 5situations Telepsychiatry should be readily available in emergency rooms to 6speed up mental health diagnosis and referral for treatment and the very 7complicated involuntary commitment process Also, the second involuntary 8commitment exam could often be completed locally – particularly when 9patients have clinically stabilized awaiting bed availability at the receiving 10hospital 11 12 Second, all mental health systems providing acute and outpatient 13services should be marked by system fluidity with a smooth continuum of 14care Ideally, most patients with severe mental disorders should have a 15mental health clinical home assignment similar to the primary care medical 16home system in the Community Care of North Carolina (CCNC) system 17Mental health providers need integrated knowledge of primary care services 18in their LME catchment area The mental health system would be greatly 19served by the availability of advanced nurse level case management 20services to assist with patient communication and education and chronic 21condition management, especially for those with severe and persistent 22mental illness and/or co-occurring disorders Vertical and horizontal 23electronic integration among medical providers such as hospitals, local 24medical and non-medical providers for ongoing patient and new referrals, 25residential facilities, crisis services, medical homes, clinical homes, 26pharmacies, etc must be seamlessly established and maintained Recently 27enacted legislation will enable physical and mental health providers the 28ability to more easily access needed medical records, communicate 29necessary information, and more quickly procure appropriate care for 30patients 31 32 Third, an effective mental health system needs adequate hospital 33facilities capable of handling patients with dual medical and psychiatric 34diagnoses Currently, only state hospital facilities can provide dual 35medical/psychiatric services without financial strain on non-psychiatric 36hospital services A larger supply of community hospital beds is desperately 37needed to perform this function as well In an effort to incentivize increased 38supply of community hospital beds, the State recently began providing 39additional indigent care reimbursement to community hospitals housing non40Medicaid dual medical/psychiatric patients 41 Fourth, it is necessary to clearly define what mental health disorders 42and which patients qualify for state funded “safety net” services The same 43reimbursement policies should apply statewide in all LMEs for these “safety 44net” services to avoid rationing care using different eligibility standards 45 Fifth, accountability and care management standards need to be 2transparent and uniform statewide All mental health treatment decisions 3should be evidence based – similar to the CCNC disease model There should 4be a statewide consistent system of Utilization Management/ Utilization 5Review with the exact same standards used in all LMEs to ensure that 6appropriate quality measurement occurs An experienced national provider 7that regularly performs Medicaid utilization management/utilization review 8should be considered to provide training to LMEs so that they may utilize the 9same analysis techniques These same experienced utilization review 10entities may then act as agents of that provider to review high risk or high 11costs services at the local level Cost effectiveness of an LME should be 12measured including client services and overhead costs 13 14 Selected licensed professionals should be used to provide treatment 15when possible, instead of “any willing qualified provider” as currently 16mandated by federal law North Carolina should engage in the multi-year 17process to obtain a statewide Medicaid waiver to legally eliminate the 18necessity of including “any willing qualified providers” in the system as soon 19as possible In addition, mandatory national accreditation of providers will 20improve the quality of providers in each service area In turn, this will enable 21more comprehensive auditing and measurement of quality of care provided 22to residents 23 24 Sixth, the LME county assignment map should be similar to the 25Community Care of North Carolina (CCNC) networks map This will result in 26fewer LMEs which will, in turn, reduce administrative costs Also, the same 27geographical catchment areas for LMEs and CCNCs will promote the 28integration of primary care and behavioral care for the same population of 29residents 30 31Question 2: What are components of a clinical professional team 32that anchors a system of outpatient or community mental health 33services provided by physicians and non-physicians? 34 35 First, clinical workforce stability is an extremely important element of 36LME success Effective clinical teams may be composed of salaried 37employees and/or independent contractors While telepsychiatry increases 38workforce distribution, it may or may not be helpful in particular situations 39dependent upon the patient’s condition and preferences 40 41 Second, an example of a feasible plan that provides a continuum of 42care would be to center activities around a psychiatrist trained in community 43psychiatry The psychiatrist would serve the important role of medical 44oversight of the care plans of local patients that may include treatment and 45follow-up with several provider types For such a plan to work, it would be 46necessary for the community hospital psychiatrists to have the same access 1as a state hospital to local mental health resources when discharging 2patients This may be achieved by the addition of local case managers 3(described above) who interface between public and private physicians and 4the LME system to ensure that all patients have access to needed MH/DD/SA 5resources Within this plan, primary care physicians need a direct connection to a 8psychiatrist on an outpatient basis, as often psychiatric assistance is only 9readily available for inpatients Once a psychiatrist has evaluated and 10diagnosed a patient, it may then be possible for the primary care physician 11to successfully manage patient medication and the Person-Centered Plan 12dependent upon the circumstances Primary care physicians paired with 13non-physician mental health providers (such as social workers, masters level 14psychologists, marriage and family therapists, and licensed professional 15counselors) not equal the medical treatment ability of a psychiatrist for 16quadrant IV patients because both are outside of their scope of practice 17 18 Regardless of the system structure, unified access to MH/DD/SA 19medical records, perhaps through a statewide MH/DD/SA electronic health 20records repository, is essential to ensure the highest quality of care possible 21is provided to all patients Electronic prescribing capacity will also serve to 22enhance many facets of a successful service delivery system 23 24 There is currently a shortage of substance abuse services providers 25with adequate training The supply of qualified substance abuse service 26providers needs to be increased because substance involvement complicates 27a high percentage of problems of individuals in all disability groups Those 28counselors must be able to successfully integrate their services and freely 29communicate with all providers supported by appropriate releases for the 30ongoing exchange of medical information 31 32 A strong case management system provided by skilled professionals is 33an essential component of mental health system reform Case management 34is an established and necessary function for the legislated “community 35support services”, whereas the additional “skill building” is less well defined 36and diverts scant resources in an unreliable manner As per the Division of 37Medical Assistance, the current definition of “community support services” 38should be revised to reinforce the case management system and 39limit/eliminate “skill building” 40 41 It cannot be emphasized enough – proper assessment and diagnosis is 42the keystone to proper service Ideally, diagnosis should be performed by 43the most trained, most experienced professionals available with appropriate 44consultation with clinical specialists as available Primary care and mental 45health specialists should collaborate as appropriate concerning patient 46assessment and diagnosis Evidence-based treatments can then be 1administered by trained providers who keep current on new modalities and 2developments in those fields Progress indicators and outcome measures 3must follow treatment with re-assessment of diagnosis when treatment is not 4progressing 6Question 3: What Person-Centered Plan (Plan) elements are needed 7to ensure management control for services provided by clinical and 8non-clinical professionals? (see Addendum B for a detailed description) 10 The necessary elements of a Person-Centered Plan (Plan) include the 11following evidence-based components: comprehensive clinical assessment, 12current diagnosis(es), medication information, action plan, and crisis plan 13All current providers should be contacted to provide information for the Plan 14(including primary care) This is useful information for providers who may 15reference the Plan while providing ongoing medical care The Plan should be 16developed with input from the patient, family, caregivers, etc to benefit from 17multiple perspectives and to promote involvement from all parties A 18therapeutic alliance with the patient is the first step to providing optimal 19care With authorization, additional communication and coordination with 20the patient’s natural support system provides valuable information and 21monitoring 22 23 Currently, the physician signature line on the Plan must be signed by a 24physician, licensed psychologist, nurse practitioner, or physician’s assistant 25The professional who signs the Plan also indicates that they have (1) 26personally evaluated the patient, (2) reviewed the Plan and the 27accompanying information, or (3) personally evaluated the patient and 28reviewed the Plan and the accompanying information Through this process, 29the professional certifies that the Plan meets the North Carolina definition of 30“medical necessity.” Unfortunately, there are many instances where the 31professional just signs the Plan with little real connection with the patient or 32much awareness of the patient’s clinical status and treatment needs 33 34 A better approach would be to require that the professional who signs 35and certifies the Plan have an existing professional relationship with the 36patient and have some understanding of the patient’s mental health needs 37The professional also should have some knowledge of the services being 38approved and the array of services available in the community When a 39primary care physician is asked to certify a Plan, patients receiving care as 40outlined in their Plan ideally would have a “medical home” in the 41signing/certifying physician’s practice If this criterion cannot be met, then 42another professional more familiar with the patient, if available, should sign 43the Plan (Note: While Medicaid patients have primary care medical homes 44via the Community Care of North Carolina (CCNC) networks providing this 45established relationship, many non-Medicaid patients are in need of a similar 46primary care medical home to ensure resources are appropriately expended.) The physician signature line also should be moved to an area of the 3Plan relevant to physicians and should be easy for physicians to access In 4addition, information included on the Plan including diagnoses, medication 5history, and the crisis plan should be grouped together for easy access and 6review by primary care providers The Plan also should include contact information for the patient’s LME 9for easy access in case the professional relationship with the provider(s) is 10not working out and outcomes are not being achieved 11 12 There is considerable debate among the provider community 13concerning how the Plan could be streamlined Some providers feel the 14current Plan form is overly comprehensive and just the time for someone to 15complete or read it takes needed time and resources away from the direct 16provision of clinical care Consequently, some providers fail to utilize the 17Plan at all and feel that it should change to become a more efficient 18communicator of relevant information regarding the patient’s diagnosis and 19treatment 20 21 Question 4: What are the accountability standards for outpatient 22treatment and community services from the provider perspective? 23 24 Evidence based mental health treatment should be the standard of 25care in the mental health system to the greatest extent possible Measuring 26best practices in behavioral health is a somewhat new concept as compared 27to the history of measuring best practices in physical health Although some 28American Psychiatric Association Guidelines and integrated care guidelines 29have been created, there are relatively few psychiatric treatment standards 30currently in existence 31 32 Coordination of care between providers, hospitals, LMEs, etc., or at the 33very least accessing other providers’ patient records, will be essential to 34implementing any evidence based best practices within the mental health 35system To promote integration of physical and mental health care, it is 36entirely appropriate that primary care standards concerning physical health 37be incorporated into best practices utilized for mental health treatment An 38example of this would be using the established medical criteria for 39monitoring for the appearance of metabolic syndrome in patients receiving 40atypical antipsychotic medications 41 42 Assessment of best practices concerning the efficacy of various 43treatment programs is definitely needed Such assessments should include 44inquiries such as how much contact with a mental health treatment provider 45is necessary for the program to be effective 46 There may be substantial difficulties with determining how evidence 2based treatment will be measured, monitored and enforced in the mental 3health setting Commonly used pay for performance initiatives may be 4modified to require only reporting the number of patients with a certain 5condition that receive certain treatment It may be possible for LME Medical 6Directors and Quality Management sections to develop suitable fidelity 7scales and other outcome measures Mental health psychotropic formulary compliance with evidence based 10practices may also be difficult Current MH/DD/SA recommendations 11appropriately not include a “fail first” requirement concerning usage of 12cheaper drugs to see if they are effective prior to prescribing a higher cost 13alternative These recommendations also include a “grandfather” provision 14enabling patients to continue taking the same medication that has proven 15therapeutic 16 17 Credentialing issues associated with outpatient mental health 18treatment are also complex The state’s current “any willing qualified 19provider” standard is sometimes problematic because it is too broad and 20does not easily exclude inexperienced or less capable providers However, 21credentialing requirements that are too numerous and too specific may result 22in a net decrease in the number of available providers Providers who tend 23to diagnose what they usually treat are inherently problematic as well 24 25 Recredentialing issues such as continuing competency requirements 26are also very important to the overall quality of services being provided 27Provider performance needs to be assessed, but it should not be solely based 28on outcomes - accurate billing, staff relations, incidents, and other 29appropriate measures should also be included 30 31 There is also considerable debate concerning whether all professionals 32should be allowed to provide any outpatient service that they wish to 33provide While each professional’s legal scope of practice is defined in 34statute, what services someone can competently provide is also determined 35by their professional training and experience To aid in ensuring higher 36quality outpatient care, there is a need to distinguish what 37education/professional experience is required for treatment of what 38conditions Designations concerning which practitioners may treat certain 39conditions for designated age categories may be helpful in this regard 40However, too much detail in such a plan may be harmful as it may result in 41providers being barred from performing services they are able to 42competently provide For example, out of necessity, most rural mental 43health providers have a wider scope of practice than urban providers that 44has been obtained by self-training out of necessity due to workforce 45shortages Lack of psychiatric availability is an ongoing, major concern of 1primary care providers However, mandating that a workforce be available in 2all locations at all times is difficult to achieve Certain types of “incident to” billing are also of great concern The 5Division of Medical Assistance has again extended the deadline for use of H 6Codes until June 30, 2010 (subject to change) H Codes are billed for 7services provided by provisionally licensed non-physician providers, such as 8psychologists, substance abuse counselors, social workers, etc for services 9provided to Medicaid patients The availability of services performed by paid 10provisionally licensed providers expands the available workforce Previously, 11many LMEs often utilized the H Codes in practice settings where all providers 12were closely collaborating including the provisional licensee and their 13supervising physician Currently, the supervising physician rarely has a close 14relationship with the provisional licensee and is rarely even present, as the 15current DMA policy only requires that the supervising physician be 16“available.” Many physicians not feel comfortable with their Medicaid 17provider number (now NPI) being used to bill H Codes for the provisional 18licensee services with whom they have little or no involvement Although 19the provisional licensee has a supervisor in their own profession, the higher 20supervision level (MD) is favored for Medicaid billing purposes 21 22 Question 5: What are appropriate accountability standards for 23LMEs? 24 25 LMEs should ensure that mental health clinical homes are available for 26all patients in need of such services The LME should also be responsible for 27maintaining adequate clinical workforce availability for consultation and 28treatment to the entire LME catchment area 29 30 Many providers and LME officials question whether LME accountability, 31as currently measured, is meaningful It is unknown how the considerable 32and time-consuming LME accountability data as per state standards is being 33interpreted and utilized Some of the current language used in LME 34measurement could be clarified to allow for easier LME assessment In any 35event, standard assessment software is needed for all LMEs so that data may 36be appropriately compared amongst them 37 38 Ideally, more outcome-based measures are needed, as these would 39allow assessment of treatment approaches, and provide the ultimate 40assessment of the LME’s effectiveness Rather than continuing the current 41“LME Report Card” approach, there should be focus on what is truly pertinent 42to quality and the system of care.” In addition to needed outcome 43measures, other important monitoring currently done should continue, 44including items as wait time, readmission to facilities, timely access to care, 45etc 46 10 In addition, the national accreditation requirements that all LMEs are 2currently being required to implement are substantial Therefore, it is fair to 3ask whether state accountability measures should be reduced and saved 4time and resources devoted to clinical care Question 6: What are the accountability standards for inpatient 7treatment? There is a state-wide shortage of psychiatric beds Factors that have 10contributed to this include: (1) the state’s larger than expected population 11growth in the last several years; (2) local inpatient units closing because of 12difficulties maintaining financial viability; (3) ineffective efforts by LMEs and 13the agencies they fund to manage outpatient crises with early intervention 14and stabilization, which subsequently result in hospitalization; (4) planned 15cutbacks in the state-run facilities for cost savings; and (5) others In 16response, DHHS has attempted to increase the number of state-funded 17community psychiatric inpatient beds This effort should be continued and 18enhanced 19 Increasing the number of available community psychiatric inpatient 20beds will lessen the strain on local emergency rooms monitoring and holding 21patients prior to transfer to one of the four state psychiatric hospitals In 22addition, increased local psychiatric bed capacity will allow more patients to 23be treated in their own communities and save expensive state beds for more 24severely ill patients who require longer duration hospitalizations As of 25February 2009, 40% of inpatients in the four state hospitals had a length of 26stay less than seven days - DHHS wants to decrease this percentage 27Mandating that local psychiatric inpatient beds be utilized first has been 28considered 29 30 Creating increased local inpatient capacity is a lengthy and expensive 31process It takes approximately one year for a hospital to convert med/surg 32beds into a psychiatric or substance abuse unit which would be licensed by 33the State and meet Medicare and Medicaid requirements DHHS contracted 34for 91 beds from various local hospitals with plans to increase this number in 35the future If close-to-Medicaid per diems are paid to hospitals and 36physicians, these amounts not provide enough financial incentive for local 37hospitals convert available/ unused licensed beds 38 39 Staffing of an inpatient psychiatric unit is the largest ongoing expense 40The general staffing needs are defined by DHHS and the Centers for 41Medicare and Medicaid Services (CMS) Professionals involved include 42psychiatrists, masters level therapists, psychiatric nurses and other 43registered nurses, certified nursing assistants and others A common staffing 44pattern for an adult unit with a census of 10-18 patients includes two 45registered nurses and three or four certified nursing assistants 46 11 Unfortunately, successful operation of inpatient hospitals that offer 2quality and safe care for some of the most vulnerable patients has not 3always occurred in the last few years In response, funding has been 4stopped and started at some facilities, investigations conducted, 5accreditations lost and reinstated, and public trust has been shaken 6Changing the culture of state run facilities is a priority, as is the need for 7comprehensive safety standards to ensure patients and staff are functioning 8in a safe environment To provide improved administrative effectiveness, 9DHHS may consider using non-profit hospital management companies and/or 10the state’s medical schools 11 12 As a primary focus of inpatient care is to stabilize patients as quickly as 13possible and move them to a lower level of care, discharge care coordination 14with outpatient treatment resources is integral to improved outcomes This 15may be more easily achieved by increasing psychiatric bed availability in 16community hospital settings because of greater awareness of local resources 17and greater convenience for families and caregivers involved in discharge 18planning 19 20Recommendation: The NCMS Mental Health Task Force recommends 21that the Board of Directors adopt this report and forward it to appropriate 22North Carolina Department of Health and Human Services for consideration 23in mental health system reform planning activities (action) 12 Addendum A - Definition of Clinical Home North Carolina Psychiatric Association A District Branch of the American Psychiatric Association Community & Public Psychiatry Committee Proposal Clinical Home: Assessment and Stabilization Service 02-28-08 To restore the safety net, each LME needs to have at least one publicly funded safety net clinic or clinical home, depending on the size of the catchment area This model is designed to permit the clinical home to be operated by the LME or through a contracted provider Problems:  Current assessments are often inadequate: when conducted by a provider, they can be geared more to ensuring the provider’s services are used than to identifying a patient’s comprehensive needs Assessments can be skimpier than clinically indicated Psychiatric assessments are often inadequate and not reflect contemporary standards of diagnosis and evidence-based treatments Medical assessments are often inadequate, with inadequate integration of psychiatric and medical problems and referral to appropriate medical treatment  Provider networks are inadequate to care for some populations (indigent and working poor populations) or to provide some specialized evidence-based treatments  The current system, relying as it does on “choice” and marketing, short-changes quality clinical care individualized to a patient’s problems, based on evidence, and likely to improve the patient  The current system has many gaps of communication and services between disparate providers, with poor communication and care coordination Populations to be served:  All North Carolinians with mental illness or addiction who cannot receive needed services elsewhere, whether because of funding (medically indigent or working poor) or because of complexity and severity of clinical condition 13 Functions:  Safety Net  Psychiatric Assessment o Comprehensive, multi-disciplinary assessment, one component must be a thorough evaluation by psychiatrist o Primary care and Primary care linkage  Initial proposed treatment plan with recovery-oriented evidence-based interventions for the working diagnosis o Stabilize and refer (if necessary, if feasible) to network providers, primary care etc o Guarantee of psychiatric services  development and implementation of psychiatric treatment plan  consultation (with primary care or other network provider)  psychotropic medication management (by the psychiatrist or PCP with consult from psychiatrist)  UM – Short-term predictive measures (soon after the patient is referred progress report from the provider would be required to determine if patient has improved, stayed the same or gotten worse If the latter, patient would be referred back to psychiatrist for reassessment and reevaluation of the treatment plan If patient has plateaued, provider will be alerted to review the plan.)  Clinical Oversight  QM – Continuous Quality Improvement  24/7 emergency service for all o Until attached to a First-Responder provider o As a temporary backup for a failed first responder provider, a failed /inadequate first response or a clinical resource to trouble-shoot solutions with provider about ability to respond in the future Necessary Elements: Funding  Market level funding for psychiatrists – in effect, 50% of personnel costs need to be subsidized  Adequate nursing, professional, substance abuse, psychotherapy, clerical, staff to support the mission  Medications – sample availability and Medication Access Review Program  medical assessment (fear that grants will not be sustainable)  labs, tests (including psychological testing although may be rarely needed) 14 Addendum B – Description of Comprehensive Clinical Assessment (CCA) and Person-Centered Plan (Plan) Comprehensive Clinical Assessment The Comprehensive Clinical Assessment (CCA) may include but is not limited to: T1023 Diagnostic Assessment 90801 Clinical Evaluation/Intake 90802 Interactive Evaluation 96101 Psychological Testing 96110 Developmental Testing (Limited) 96111 Developmental Testing (Extended) 96116 Neuropsychological Exam 96118 Neuropsychological Testing Battery H-0001 Alcohol &/or Drug Assessment 10 H-0031 Mental Health Assessment 11 Evaluation & Management (E/M) Codes 12 YP830 Alcohol &/or Drug Assessment-non-licensed provider (State $ only) 13 Current medications and a list of allergies All current providers should be contacted to provide information for the Plan (including primary care) a The Plan should include both an action plan and a practically-worded crisis plan, the most current diagnosis, assessment, and medication information This is important for use by care providers who may reference the Plan while providing ongoing medical care b The Plan should be developed with input from the patient, family, caregivers, etc to benefit from multiple perspectives and to promote involvement from all parties A therapeutic alliance with the patient is the first step to providing optimal care With permission, communication and coordination with the patient’s natural support system provides both valuable information and monitoring Person-Centered Plan 15 Required Content for a complete Plan will include the following: Identifying Information Participants Involved in Complete Plan Development Personal Dialogue/Interview Family, Legally responsible person, Informal Supports Dialogue/Interview Summary of Assessments and Observations Action Plan Crisis Prevention Crisis Response Crisis Prevention/Crisis Response (Continuation) Signature Page 10 Update/Revision page and Update/Revision Signature page The professional signing the Plan may also wish to require a section concerning objective findings or examination such as a Mental Status Examination Medical information included in the Plan should be grouped together for easy access and review by primary care providers The physician signature line on the Plan must be signed by a physician, licensed psychologist, nurse practitioner or physician’s assistant indicating that they have either personally evaluated the patient or reviewed the Plan and accompanying information (or both)and by that process have determined the Plan meets the North Carolina definition of “medical necessity.” Therefore, the physician signature line should be located in the area that is relevant to physicians and should be easy for physicians to access The Plan should also include contact information for the patient’s LME for easy access in case the professional relationship with the provider(s) is not working out and outcomes are not being achieved 16 ... Privatization that has occurred due to mental health reform does not 11consistently provide fundamental services needed by the severely and 12persistently mentally ill Such fundamental services are needed... Second, all mental health systems providing acute and outpatient 13services should be marked by system fluidity with a smooth continuum of 14care Ideally, most patients with severe mental disorders... easily overlap with the fourteen CCNC networks which would 27promote further integration of primary and mental health care This 28integration would broaden and enhance the available mental health