Current through Register Vol. 51, No. 19, September 20, 2024
A. The
Department shall reimburse for the services in §§C-I of this
regulation under mental health case management when these services have been
documented, pursuant to the requirements in this chapter, as
necessary.
B. Case management
services shall be coordinated with, and may not duplicate activities provided
as part of, institutional services and discharge planning activities.
C. Comprehensive Assessment and Periodic
Reassessment.
(1) Assessment or reassessment
involves the participant's stated needs and review of information concerning
the participant's mental health, social, familial, cultural, medical,
developmental, legal, vocational, and economic status to assist in the
formulation of a care plan.
(2) The
assessment or reassessment of the participant's stated needs and service needs
is conducted by the community support specialist and incorporates input from
the participant, family members, and friends of the participant, as
appropriate, and community service providers, such as mental health providers,
medical providers, social workers, and educators, if necessary.
(3) A home visit, or visit at another
location suitable to the participant's needs, by the community support
specialist or community support specialist associate is required every 90
days.
(4) After an initial
assessment, each participant shall be reassessed every 6 months.
D. Development and Periodic
Revision of a Specific Care Plan.
(1) After
the initial assessment is completed, a care plan shall be developed.
(2) After the care plan is developed, it
shall be updated every 6 months in conjunction with the participant's schedule
for reassessments, to ensure that all services being provided remain
sufficient.
(3) The participant, a
legal guardian, the participant's family or any significant others with the
participant's consent, shall participate with the community support specialist,
to the extent practicable, in the development and regular updating of the
participant's care plan.
(4) The
specific care plan shall:
(a) Be developed
with the participant and based on the assessment;
(b) Specify the goals and actions to address
the mental health, medical, social, educational, and other services needed by
the participant;
(c) Include the
active participation and agreement of the participant, the participant's
authorized health care decision maker, if applicable, and others designated by
the participant; and
(d) Identify
strategies to meet the goals and needs of the participant.
(5) The care planning process may include, as
necessary and appropriate:
(a) The care
planning meeting, which includes the participant, and with the participant's
consent, providers, family members, other interested persons, as appropriate,
for the purpose of establishing, revising, and reviewing the care
plan;
(b) The development and
periodic updating of the written, individualized care plan based on the
participant's needs, progress, and stated goals;
(c) Transitional care planning that involves
contact with the participant, or the staff of a referring agency, or a service
provider who is responsible to plan for continuity of care from inpatient level
of care or an out-of-home placement to another type of community service;
and
(d) Discharge planning from
mental health case management services, when appropriate and when goals for
mental health case management have been achieved.
E. Referral and Related
Activities.
(1) The community support
specialist or associate, under the direction of a community support specialist,
shall assure that the participant, has applied for, has access to, and is
receiving the necessary services available to meet the participant's needs,
such as mental health services, resource procurement, transportation, or crisis
intervention.
(2) The community
support specialist shall take the necessary action when the services identified
under §D of this regulation have not occurred.
(3) The linkage process shall include:
(a) Community support development by
contacting, with the participant's consent, members of the participant's
support network, for example, family, friends, and neighbors, as appropriate,
to mobilize assistance for the participant;
(b) Crisis intervention by referral of the
participant to services on an emergency basis when immediate intervention is
necessary;
(c) Arranging for the
participant's transportation to and from services;
(d) Outreach in an attempt to locate service
providers which can meet the participant's needs, and
(e) Reviewing the care plan with the
participant and with the participant's family and friends, as appropriate, so
as to enable and facilitate their participation in the plan's
implementation.
F. Monitoring and Follow-Up Activities.
(1) A mental health case management provider
shall monitor, as frequently as necessary, the activities and contacts that are
considered necessary to ensure the care plan is implemented and adequately
addresses the participant's needs, and include:
(a) The participant, and
(b) With proper consent:
(i) Family members and friends, if
appropriate; and
(ii) Other service
providers, if any.
(2) In addition to the requirements outlined
in §E of this regulation, the case management provider shall conduct,
every 6 months, a reassessment to determine whether:
(a) Services are being furnished in
accordance with the participant's care plan;
(b) Services in the care plan are adequate;
and
(c) If the needs of the
participant change, and if applicable, necessary adjustments are made to the
care plan, including referrals for services.
(3) The mental health case management
provider shall:
(a) Follow up any service
referral to determine whether the participant made contact with the service
provider that the participant was referred to; and
(b) Monitor service provision on an ongoing
basis, to ensure that the agreed-upon services are provided, are adequate in
quantity and quality, and meet the participant's needs and stated
goals.
(4) The mental
health case management provider may revise the care plan to reflect changing
needs identified from the service monitoring.
G. Mental health case management may include
contacts with non-participants that are directly related to identifying the
needs and supports for helping the participant to access services.
H. The mental health case management provider
shall engage in participant advocacy, including:
(1) Empowering the participant to secure
needed services;
(2) Taking any
necessary actions to secure services on the participant's behalf; and
(3) Encouraging and facilitating the
participant's decision making and choices leading to accomplishment of the
participant's goals.
I.
Service Provision. Mental health case management services shall be provided in
accordance with the following:
(1) For
participants in Level I-General, a mental health case management provider shall
provide a minimum of 1 and a maximum of 2 days of service each month;
(2) For participants in Level II-Intensive, a
mental health case management provider shall provide a minimum of 2 and a
maximum of 5 days of service each month; and
(3) One additional unit of service above the
monthly maximum may be billed during the first month of service to a
participant in order to complete the comprehensive assessment.