Sec. 10.09.45.06. Covered Services

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.