Current through Register Vol. 35, No. 18, September 24, 2024
A. Comprehensive community support services
(CCSS) shall coordinate and provide necessary services and resources to
eligible clients and families to promote recovery, rehabilitation and
resiliency.
B. These culturally
sensitive services shall identify and address the barriers that impede the
development of skills necessary for independent functioning in the community as
well as strengths, goals and measurable objectives, which may aid the client or
family in the recovery or resiliency process.
C. CCSS shall address goals as identified by
the client or family specifically to meet recovery and resilience based
outcomes in the areas of independent living, learning, working, socializing and
recreation.
D. CCSS shall be
provided to children, youth and adults with significant behavioral health
disorders and who meet other criteria as identified by the
collaborative.
E. CCSS shall be
provided in compliance with the medical assistance division (MAD) definition of
medical necessity and shall be furnished within the MAD benefits.
F. CCSS shall be furnished within the scope
and practice of the provider's respective profession as defined by state law,
and in accordance with applicable federal, state and local laws and
regulations.
G. An assessment of
baseline functioning shall be performed within 10 working days of the client's
admission into CCSS services. The assessment shall evaluate and document the
client's specific functional effectiveness in multiple skill domains based on
the desired outcomes of the client or family.
(1) Functional level determination shall
identify domains in which functional limitations precipitated by the behavioral
health disorder are present. The diagnoses and assessments shall be the basis
for the comprehensive client or family driven goal directed, measurable service
plan
(2) CCSS eligible clients
shall have one designated agency that will have the primary responsibility of
partnering with the client and family for the purpose of implementing the
comprehensive service plan.
H. Within the CCSS agency, a primary
community support worker (CSW), under the documented supervision of the CCSS
supervisor, shall be identified on the comprehensive service plan and shall
partner with the client and family for the purpose of coordinating and
facilitating recovery and resiliency directed team meetings. The CCSS
supervisor shall sign, with name, credentials, and date, the initial service
plan indicating that he has reviewed and approved the comprehensive service
plan and each revision as it occurs.
I. Community support activities and relevant
providers shall be clearly identified in the comprehensive service plan. The
primary CSW shall coordinate the service plan without duplication by the other
service providers. The CCSS comprehensive service plan shall be completed no
later than 30 calendar days of the client's admission into CCSS services and
specify recovery and resiliency strategies to include:
(1) the community support(s) and any other
rehabilitative and treatment interventions needed for the client to achieve his
specified service goals and to meet recovery and resiliency outcomes;
(2) the CCSS staff responsible for each
recovery and resiliency intervention and the frequency of the planned
interventions;
(3) the client's
relevant diagnoses and other risk factors that place him at risk of further
diagnoses;
(4) measurable goals and
objectives identified by the client and family as their comprehensive service
plan priorities to meet desired recovery and resiliency outcomes;
(5) a recovery/ resiliency management
plan;
(6) a crisis management plan
to address after-hours crisis situations including actions to be taken by
client, family and natural supports;
(7) potential service plan barriers and
applicable strategies; and
(8) if
requested, advanced directives related to client's behavioral
healthcare.
J. CCSS
shall include the development of crisis plan interventions, as defined in an
individual crisis plan, as a component of overall CCSS comprehensive service
plan. If the client has or requests an advance directive, the crisis plan may
be incorporated into the advance directive. The individualized crisis plan
shall support the client and family in the management of crisis situations
outside of regular business hours to develop or enhance the client's ability to
make informed and independent choices.
(1) the
crisis plan shall include the following requirements, which shall be formulated
on admission to CCSS by the CCSS team, client, family, legal guardian and other
interested parties.
(a) Risk assessment:
Specify a process to assess potential risk and specify an algorithm of
community resources to address by risk level that ranges from immediate (i.e.
911 or first responders) to intermediate (e.g. call to crisis line) to moderate
(call for a clinic appointment). Specify a process to identify benchmarks that
indicate when a crisis is appropriate reconciled.
(b) Client/family education: Provide the
client and family education on community resources to be accessed during crisis
situations. Each family and client shall be provided basic verbal communication
techniques to help de-escalate a potential crisis situation.
(c) Internal communication: Crisis events are
discussed in the CCSS team meeting to ensure all risk factors are identified
and known by all team members.
(d)
Face-to-face assessment: CCSS team member shall make a face-to-face visit as
soon as possible, but no more than 48 hours after notification of a crisis, and
complete an updated assessment for presentation to the team.
(e) Research past crisis situations for
antecedent, precipitant, and consequent behaviors and discuss with the client
or family to identify strategies or objectives likely to prevent
crises.
(f) Identify alternative
interventions that may be initiated during crisis situations, including
pre-crisis or crisis instructions identified by the client or family.
(g) Incorporate client and family outcomes as
benchmarks or measures of when the crisis is over.
(h) Revise crisis plan over time based on
newly identified triggers and what is known to be effective.
(i) Document behavioral benchmarks (e.g.,
number of runs, self-injury, assaults, etc., and what worked).
(2) The negotiated crisis plan
shall triage for differing levels of intensity and severity of crisis events
and may identify other types of interventions that may include:
(a) residential services for
stabilization;
(b) crisis respite
services;
(c) wrap around
services;
(d) increased family and
community support specialist capacity to manage crisis situations;
(e) activation of advance directive
instruction; and
(f) utilization of
emergency room (ER) and other emergency response supports.
K. Every 90 days after
implementation of the comprehensive service plan, the CCSS team, in partnership
with the client and family, shall track and provide detailed documentation
demonstrating progress made over time relating to the CCSS service goals,
objectives and client/family designated recovery or resiliency outcomes. These
shall be documented in the service plan updates with modifications made based
upon barriers identified or redefined goals and objectives and future
needs.
L. The follow up assessment
shall document the current status of the client and family designated
measurable recovery or resiliency functional outcomes.
M. Individualized CCSS interventions shall
address the following objectives, as indicated in the assessment and
comprehensive service plan:
(1) community
services and resources available to support the client's achievement of his
functional CCSS service goals and objectives;
(2) assistance in the development of
interpersonal, community coping and functional skills (i.e., adaptation to
home, school and work environments), utilizing evidence-based practices to
support the skills development in the following domains:
(a) socialization skills;
(b) developmental issues as identified in the
assessment;
(c) daily living
skills;
(d) school and work
readiness activities; and
(e)
education and management of co-occurring illness;
(3) facilitating the development and eventual
succession of natural supports in the workplace, housing/home, and social and
school environments;
(4) provision
of client and family education as appropriate regarding:
(a) self-management of symptom monitoring,
illness management, and recovery and resiliency skills;
(b) relapse prevention skills;
(c) knowledge of medication and potential
side effects;
(d) motivational and
skill development in taking medication as prescribed;
(e) ability to identify and minimize the
negative effects of symptoms which potentially interfere with the client's
activities of daily living; and
(f)
as indicated, supports to the client to maintain employment and school or
community tenure;
(5)
facilitating the client's abilities to obtain and maintain stable
housing;
(6) any necessary
follow-up by the CSW to determine if the services accessed have adequately met
the client's needs.
N.
Cultural competence shall be demonstrated by the CCSS provider through the
agency's policies, procedures, training, outreach and advocacy efforts, and
throughout the array of service delivery framework.
O. The CCSS provider shall demonstrate
through a documented internal quality monitoring process that on average (60%
or more) of CCSS services are delivered face-to-face and in vivo (where client
is in the community).
P. The CSW
shall provide routine follow-up to determine if the services accessed have
adequately met the client's rehabilitative, recovery, resiliency, and treatment
needs and document findings.
Q.
CCSS shall be offered at convenient times and locations to meet the needs of
the client and family; the CCSS provider will actively work to eliminate
language, financial, and other barriers to service.
R. For clients and their families: The CSW
shall make every effort to engage and partner with the client and family in
achieving rehabilitative, recovery, and resiliency goals. Barriers to engaging
the client or achievement of the service goals will be identified and utilized
to amend the service plan interventions.
S. When CCSS is provided by a certified peer
or family specialist, CCSS functions shall be performed with a special emphasis
on recovery and resiliency values and process, such as:
(1) empowering the client to have hope for,
and participate in, his own recovery;
(2) assisting the client to identify
strengths and needs related to attainment of independence in terms of skills,
resources and supports, and to use available strengths, resources and supports
to achieve independence;
(3)
assisting the client to identify and achieve his personalized recovery and
resiliency goals; and
(4) promoting
the client's responsibility related to illness self-management.
T. CCSS shall be subject to the
limitations and coverage restrictions as defined by 8.315.6 NMAC, Comprehensive
Community Support Services.
U.
Behavior management skills development service (BMS) interventions are distinct
and different from CCSS and shall not be considered to be CCSS.
V.
Eligible providers: CCSS
shall be delivered by a certified mental health agency.
(1) The agency shall be a legally recognized
entity in the United States, qualified to do business in New Mexico, and shall
meet standards established by the state of New Mexico or its designee, and
requirements of the funding source.
(2) CCSS shall be provided in the following
type of entities:
(a) federally qualified
health center (FQHC);
(b) Indian
health service (IHS) hospital or clinic;
(c) tribal-638 hospital or clinic;
(d) community mental health center
(e) core service agency (CSA); or
(f) an agency otherwise certified as a CCSS
agency by New Mexico children, youth and families department (CYFD) or New
Mexico department of health (DOH)
(3) Eligible clients who are 18 through 20
years of age may be served by an agency certified for CCSS by CYFD or DOH, as
indicated.
W.
Staff qualifications: Clinical services and supervision by
licensed behavioral health practitioners shall be in accordance with their
respective licensing board regulations.
(1)
Minimum staff qualifications for the CSW:
(a)
shall be a minimum of 18 years of age; and
(b) shall hold a bachelor's degree in a human
service field from an accredited university and one (1) year relevant
experience working with the target population; or
(c) shall hold an associate's degree in a
human service field from an accredited college and have a minimum of two (2)
years of experience working with the target population; or
(d) shall be a high school graduate or have a
general education development (GED) and shall have a minimum of three years of
experience working with the target population; or
(e) shall be certified as a certified peer
specialist (CPS) or certified family specialist (CFS).
(2) Minimum staff qualifications for the CCSS
program supervisor:
(a) shall hold a
bachelor's degree in human services field from an a accredited
university;
(b) shall have a four
(4) years relevant experience working with the target population; and
(c) shall have one year demonstrated
supervisory experience.
(3) Minimum staff qualifications for the
clinical supervisor (The clinical supervisor and the CCSS program supervisor
may be the same individual):
(a) shall be a
licensed independent practitioner (i.e., psychiatrist, psychologist, LISW LPCC,
LMFT, psychiatrically certified CNS) practicing within the scope of their New
Mexico licensure;
(b) shall have
one year documented supervisory experience; and
(c) shall provide documented clinical
supervision on a regular basis to the CSW, CPS and CFS.
(4) Minimum staff qualifications for CPS:
(a) shall be a minimum of 18 years of
age;
(b) shall have a minimum of
high school diploma or GED;
(c)
shall be self-identified as a current or former consumer of mental health or
substance abuse services and have at least one year of mental health or
substance abuse recovery; and
(d)
shall have received certification as CPS.
(5) Minimum staff qualifications for CFS:
(a) shall be a minimum of 18 years of
age;
(b) shall have a minimum of
high school diploma or GED;
(c)
shall have personal experience navigating any of the child-family-serving
systems or advocating for family members who are involved with the behavioral
health systems; shall have an understanding of how these systems operate in New
Mexico;
(d) if the individual is a
current or former consumer, he shall be well- grounded in his symptom
self-management; and
(e) shall have
received certification as a CFS.
X.
Staff training requirements:
(1) The minimum CCSS staff training completed
for all CSWs shall be documented in the personnel record and include:
(a) an initial training comprised of 20 hours
of documented training or education drawn from an array of the following areas,
to be completed within the first 90 days of employment as a CSW:
(i) clinical and psychosocial needs of the
target population, including cultural competency with regard to race, religion,
national origin, sex, physical disability and other community- specific
characteristics;
(ii) psychotropic
medications and possible side effects;
(iii) drugs of abuse and related
symptoms;
(iv) crisis
management;
(v) principles of
recovery, resiliency and empowerment;
(vi) ethical and cultural
considerations;
(vii) community
resources and services, including pertinent referral criteria;
(viii) client and family support
networking;
(ix) mental health or
developmental disabilities code;
(x) children's code;
(xi) client and family centered
practice;
(xii) behavioral
management;
(xiii) treatment and
discharge planning with an emphasis on recovery and crisis planning.
(b) documentation of ongoing
training is required and maintained in the personnel record and comprised of 20
hours per year, commencing after the first year of hire, with content of the
education based upon agency assessment of staff's needs. Such assessment shall
be monitored and documented through the agency's continuous quality improvement
program and annual plan.
(2) Minimum staff training requirements for
supervisors shall be documented in the personnel record and include:
(a) the same 20 hours of documented training
or continued education as required for the CCSS CSW;
(b) a minimum of eight hours of training
specific to supervisory activities; and
(c) documentation of ongoing training
comprised of 20 hours is required of a CCSS supervisor every year, commencing
after the first year of hire, with content of the education based upon agency
assessment of staff's needs. Such assessment shall be monitored and documented
through the agency's continuous quality improvement functions.
Y.
Case
loads:
(1) Caseloads, on average,
shall not exceed a ratio of 1:20 (one CSW to 20 clients receiving
CCSS).
(2) Clients participating in
medication management as the primary focus of service are not subject to the
client- staff ratio.
(3) CSW
caseloads, of client to staff ratio of 1:20 on average, shall be monitored and
documented through the agency's internal continuous quality improvement program
through defined periodic review activities such as peer chart reviews to ensure
the agency is in caseload compliance. The agency will implement timely
corrective action when it is identified that staff ratio averages are not in
compliance.
(4) Detailed case notes
document all CCSS service intervention activities and locations of services
provided for each service span delivered and include the CCSS worker's name,
credential and date of the service delivery.
Z.
Documentation requirement:
(1) The CCSS provider shall be responsible
for consistent documentation of all service delivery. Each service delivery
case note shall include but not be limited to:
(a) date of service;
(b) service location;
(c) duration of service span (e.g.,
1:00-2:00pm);
(d) description of
the service provided with reference to the comprehensive service plan and
related service goal and objective; and
(e) the client's name, and signature and
credential of the individual delivering the service.
(i) All CCSS file documentation shall be
legible.
(ii) All CCSS service
delivery shall be consistent with the service definition
requirements.
(2) CCSS comprehensive service plan and
service delivery documentation shall be internally monitored through the
agency's continuous quality improvement functions at least quarterly to ensure
compliance with all of the certification requirements.
