cbhi services kickoff meeting september 9, 2009. 2 cbhi services kickoff meeting september 9, 20092...

CBHI Services Kickoff Meeting

September 9, 2009

2CBHI Services Kickoff Meeting

September 9, 2009 2

Welcome

Gisela Morales-Barreto


September 9, 2009 3

Plan for the Day

9:15 – 9:45 Overview 9:45 – 11:00 In-Home Therapy 11:00 – 11:15 Break 11:15 – 12:30 Therapeutic Mentoring 12:30 – 1:30 Lunch 1:30 – 2:45 In-Home Behavioral

Services 2:45 – 3:00 Break 3:00 – 4:20 Panel 4:20 – 4:30 Next Steps


September 9, 2009 4

CBHI Overview

Mission, Vision, and Values

Suzanne Fields Office of Behavioral Health for MassHealth

Children’s Behavioral Health Initiative

Overview and Implementation UpdateWorcester Crowne PlazaSeptember 9th

6

CBHI Mission

To strengthen, expand and integrate Massachusetts state services into a comprehensive, community-based system of care

To ensure that families and their children with significant behavioral, emotional and mental health needs obtain the services necessary for success in home, school and community

7

CBHI Values

Family-Driven, Child-Centered and Youth Guided

Strengths-Based

Culturally Responsive

Collaborative and Integrated

Continuously Improving

8

CBHI Vision

The Children’s Behavioral Health Initiative places the family and child at the center of our service delivery system.

Policies, financing, management and delivery of publicly-funded behavioral health services will be integrated to make it easier for families to find and access appropriate services, and to ensure that families feel welcome, respected and receive services that meet their needs, as defined by the family.

9

Implementation Update

Intensive Care Coordination and Family Support and TrainingBegan serving families on June 30th

To date approximately 100 family partners and 158 care coordinators are hired

To date approximately 1200 families have been referred and are working with the CSA’s

Care planning teams are happening!System of Care meetings are happening!Training vendor selected and orientations have started

10


Mobile Crisis InterventionService began June 30th

To date approximately 2040 interventions have occurred

The key is that the service “mobilizes” to the child and occurs in the home or community location

11


In-Home Behavioral ServicesOctober 1st implementation deadline34 unique providers across the Commonwealth

selected by the Managed Care Entities

Therapeutic MentoringOctober 1st implementation deadline51 unique providers across the Commonwealth


12


In-Home TherapyNovember 1st implementation deadline55 unique providers across the Commonwealth


Crisis StabilizationCMS update

13

SERVICE DEVELOPMENT PROCESS

Court Monitor

State of MA Plaintiffs

National Consultants

Families

Stakeholders

Providers

MCE’s

CMS

14

How do we get there?

Today is just the beginning ALL of us need to learn together

There is much that we do know but….. there is a lot that we still have to figure

out Families and Providers share what they learn Data, data, and did we mention data? For the next 2 + years- refinement will occur


September 9, 2009 15

Review of Clinical Hub Concept

Anne Pelletier Parker

Massachusetts Behavioral Health Partnership



Clinical Hub: What is it?



Care Coordination: Clinical Hubs

Intensive Care Coordination(Wraparound)

•Clinical Assessment inc. CANS•SED determination for eligibility•Medical Necessity determination

•Care coordination

In-Home Therapy•Clinical Assessment inc. CANS

•Medical necessity determination•Care coordination available

Outpatient Therapy•Clinical Assessment inc. CANS

•Medical necessity determination•Care coordination available

1818

Intensive Care Coordination(Wraparound)

•Clinical Assessment inc. CANS•SED determination for eligibility•Medical Necessity determination

•Care coordination

In-Home Therapy

•Clinical Assessment inc. CANS•Medical necessity determination

•Care coordination available

Outpatient Therapy

•Clinical Assessment inc. CANS•Medical necessity determination

•Care coordination available

Child may have 1,2, or all 3 core services

Care coordination provided by most intensive service received.

Families decide on

most appropriateinitial serviceindependently

or in consultation with helping professions such as:

•primary care,•mental health clinicians

• schools•case workers

•community orgs•faith leaders

•others

EmergencyServices

Mobile Crisis Intervention

AdditionalServices

(accessedthrough

core clinicalservices)

•Behavior Management

Therapy & Monitoring

•Family Support and Training

(Family Partners)

•TherapeuticMentoring

Care Coordination



What does it mean to be a “hub”?

Can make referrals for services that require a hub: therapeutic mentoring, in-home behavioral, and family support and training

Are responsible for coordinating care and collaborating with other service providers (e.g. convening care planning teams for ICC, making regular phone calls to collaterals, holding meetings with the family and other treatment providers).

Need to regularly connect with those “hub dependent” service providers to which you make referrals in order to coordinate care and obtain and provide updates on the youth’s progress

Remember when more than one clinical hub service provider is involved with a family, care coordination is provided by the most intensive service



“Hub dependent” What does it mean to be a “hub dependent”

service?

Referrals must come from one of the three clinical core hubs: outpatient, in-home therapy, intensive care coordination

Service will not be authorized as a “stand-alone” service; it requires a hub

There must be a goal identified on an existing individual care plan (ICP) for youth in ICC or a treatment plan for youth in IHT or outpatient that the service is required or needed to address

2121

Care Integration

Emergency Services

MassHealth BH Clinicians

Primary Care

Natural Supports

Early InterventionServices (DPH)

Probation &Courts SPED

Services(DESE)

Community Services& Supports

DCF Services& Supports

DYS Services& Supports

DMH Services

& Supports

IndividualChild

& Family

Early Education

(DEEC)

SubstanceAbuse Services

(DPH)

Faith-BasedSupport

IndividualChild &Family

Care Coordination

DDS Services& Supports



In-Home Therapy (IHT)

Overview

Performance Specifications

Medical Necessity Criteria on MCE website

Anne Pelletier-Parker Massachusetts Behavioral Health Partnership



In-Home Therapy Services

In Home Therapy Services is a structured, consistent, strength-based therapeutic relationship between a licensed clinician and the youth and family for the purpose of treating the youth’s behavioral health needs. Services are delivered by one or more members of a team consisting of professional and paraprofessional staff, offering a combination of medically necessary:

In-Home Therapy & Therapeutic Training and Support.



The In-Home Therapy Services provider:

operates from 8 a.m. to 8 p.m seven days per week, 365 days per year;

has 24-hour urgent response 365 days a year;

responds to all referrals telephonically within one business day;

responds to referrals during daytime operating hours by offering a face-to-face encounter within 24 hours.

engages in assertive outreach regarding engaging in the service

engages and supports the ESP/Mobile Crisis Intervention team in an emergency.



In Home Therapy Services may be provided in any setting where the youth is naturally located, including, but not limited to,

the home (including foster homes and therapeutic foster homes),

schools,

child care centers,

respite settings,

other community settings.



Intake In-Home Therapy Services provider

participates in discharge planning at the referring provider location;

makes every effort to meet at the time of referral or as soon as possible if the referral is initiated by the MCI Team as a diversion from out of home placement or psychiatric hospitalization;

will visit the youth and family in any safe setting within 24 hours of referral from an inpatient unit, CBAT, Crisis Stabilization or Mobile Crisis Team;

completes an initial, or updates an existing, risk management/safety plan during intake.



Initial Assessment

The In-Home Therapy Services provider completes an initial assessment within 24 hours of meeting with the youth and family.

Assessment includes:main need /focal problem, contributing factors to the main need from multiple life domains, matching interventions with an emphasis on youth/family interactions and skill building.

The In-Home Therapy Services provider completes the age appropriate CANS-MA version within 48 hours of the initial contact.



Treatment Planning & Documentation

The In-Home Therapy Services provider, in consultation with the youth, the parent(s)/guardian(s)/caregiver(s), IHT supervisors, other involved treaters, and the IHT multidisciplinary team, completes an evidence-based/best-practice guided treatment plan, including a risk management/safety plan, within seven (7) calendar days of first contact. All parties involved, including the youth, sign the treatment/care plan.

The In-Home Therapy Treatment Plan:

is solution-focused;

clearly defines interventions;

includes measurable outcomes;

assists the youth and family members in their environment to help the youth to achieve and maintain stabilization;

is synchronized with other provider’s existing plans.



The In-Home Therapy team works with the entire family, or a subset of the family, to implement focused interventions and behavioral techniques to:



problem-solving

limit-setting

effective patterns of interaction

communication

risk management

/safety planning

Intensive Family Therapy may include working with the entire

family, or a subset of the family, to implement focused, structural,

strategic, or behavioral techniques, or evidence-based interventions to

enhance



The In-Home Therapy Services team employs a multidisciplinary model, with both professionals trained in working with youth and their families, and paraprofessional staff capable of providing family members with therapeutic support for behavioral health needs.

Staff are knowledgeable about: available community mental health and substance use disorder

services within their natural service area, the levels of care,relevant laws and regulations, Systems of Care philosophy and Wraparound planning process,medical, legal, emergency, and community services available to

the youth and family.

Staffing



Staff Supervision & Consultation

The In-Home Therapy Services provider ensures that a licensed, master’s level, senior clinician provides supervision commensurate with licensure level and consistent with credentialing criteria to professional and paraprofessional staff on a weekly basis.

A board-certified or board-eligible child psychiatrist or a child-

trained Psychiatric Nurse Mental Health Clinical Specialist is available during normal business hours within one (1) hour for consultation related to treatment planning, medication concerns, and crisis intervention.

A senior-level, licensed clinician trained in working with youth is available to the staff and the supervisor 24 hours a day, seven days a week for consultation as needed.



Discharge Planning and Documentation

A discharge planning meeting is scheduled whenever the authorized decision maker decides that services are no longer desired, or the family, determines that the youth has met his/her goals and no longer needs the service, or the youth no longer meets the medical necessity criteria for In-Home Therapy.

Discharge plan includes, at minimum:identification of the youth’s needs according to life

domains,a list of services that are in place post-discharge and

providers arranged to deliver each service, a list of prescribed medications, dosages, and possible side effects, treatment recommendations consistent with the service

plan of any involved state agency.



Eligibility

All MassHealth benefit plans



FST enhanced and expanded to IHT

For MassHealth, FST is being enhanced, expanded, and renamed In-Home Therapy

MassHealth will no longer purchase FST beginning 11/1/2009

FST will remain a viable service for the non-MassHealth population depending on specific insurer



IHT vs. FST: Similarities

Home and Community Based Service Comprehensive home based assessment and

CANS Risk Management/Safety Planning Treatment Planning and Monitoring of Goals 24/7 Availability Care/Case Management – collaboration with all

services and supports Psychiatric Consultation to staff Linkage with MCI and CSA teams Behavioral Management/Parent Skills Training



IHT Ongoing Treatment Knowledge of

Wraparound and System of Care

8 – 8, 365 Days Hub for TM and IHBS Professional and

paraprofessional team supervised by licensed, master’s level clinician

FST Stabilization Not required

9 – 5, M thru F Not hub for other services Master’s level and BA

level team

IHT vs. FST: Differences



IHT Authorization Parameters

15 minute units

360 units in 90 days (13 weeks)

MCE specific document at end of day

42


Worcester, MassachusettsSeptember 9, 2009

Rick Shepler, Ph.D., PCC-SCenter for Innovative Practices a part of the Institute

for the Study and Prevention of ViolenceKent State University

All materials copyrighted 2009,Richard Shepler, Ph.D

43

In-Home Therapy

• Either a Master’s level clinician or a team approach

• Intensive family therapy in the home or other community/natural setting to: – Enhance problem-solving, limit-setting

communication – Build skills to strengthen the family – Identify and utilize community resources – Develop and maintain natural supports – Risk management/safety planning


44

In-Home Therapy, con’t• Includes:

– Assessment (comprehensive home-based, inclusive of CANS) – Development of a youth- and family-centered treatment plan – Intensive Family Therapy – Coaching– Skills training– Referral and linkage– Identification of community resources and development of

natural supports

• Available to MassHealth enrolled youth


45

In-Home Therapy (IHT): Pivotal service in a comprehensive system of care

• IHT expands the continuum of care to increase the availability of the less restrictive service options for youth at-risk of out-of-home placement due to issues related to his or her mental health


46

Continuum of Service Intensity

• A continuum of intensity based on mental health needs of the youth

• Opens up range of youth to be served


47

Typical Youth/Family Served

• Youth with serious emotional challenges with functional impairments

• Youth at-risk of placement or have significant safety issues

• Youth with multiple system involvement

• System has not engaged youth and family effectively


48

Typical Youth Served

• Multiple risk factors

• Few protective factors

• Skill set deficits: e.g. problem solving; communication; emotional regulation

• Youth who need additional supports, active facilitation, and accommodations for success (school, home, community)


49

Parents and Families

• High in stressors – Low in resources and supports

• High family conflict

• Current parenting skill set unsuccessful in dealing with youth's mental health needs

• Trust issues with the “system”

• Difficulty with service access (work, transportation, poverty)


50

IHT Benefits: Youth and Families

• Reduced out of home placements

• Mental health stabilization

• Family Stability

• Reduced involvement in Juvenile Justice System

• Increased school success


51

IHT Benefits: Other Systems

• IHT actively assesses and manages risk and safety concerns

• Cost savings to other systems

• Increases positive outcomes for other child-serving systems (school success; decreased arrest rates, decreased abuse and neglect, etc.)


52

Differences Between IHT & Traditional Services

IHTServices delivered in the home and

community24/7 availability & response by IHT team

Frequency & duration matches need

Flexible Scheduling

Lead role in service coordination

Smaller caseloads Comprehensive mix of services

OutpatientClinic-based

No 24/7 availability by team

One hour weekly appointments

Appointments during office hours

Limited opportunities for collaboration

Large Caseloads >30Therapy only


53

IHT: Key Components

1. Access and availability2. Eco-systemic assessment and intervention3. Intensity of service matches family need4. Active risk management and safety planning 5. Active intervention monitoring 6. Active support to family7. Respectful and culturally mindful engagement8. Cross-system collaboration and advocacy9. Supervisor availability and team consultation

All materials copyrighted 2009, Richard Shepler, Ph.D

54

IHT: Service of Access• Service delivered where the youth lives and functions: home,

school, and community at times that are convenient to the family

• Access to information – Family dynamics and interactional patterns– Recovery environments

• Access to people– Family – School– Court– Community– Informal supports

• Access for interventions: implemented where behaviors occur


55

Ecosystemic Assessment and Intervention

• Behavioral health interventions that impact the youth in context of his or her functional environments – Home– School– Peers– Community


56

Intensity of Service Matches Family Need

• Based on youth and family need and functional impairment

• Caseload size should reflect program intensity:

The greater the need the greater intensity the smaller the caseload


57

Active Risk Management & Safety Planning

• Active risk management; safety assessment, planning and monitoring

• Family is involved and informed

• 24/7 on call: The In-Home Therapy Services provider has 24 hour urgent response accessible by phone to the youth and family, 365 days a year.

• Immediate crisis response from In-Home Therapists with face to face response as needed


58

Active Intervention Monitoring

• IHT actively monitors interventions

• Treatment persistence


59

Active Supports

• Resource poor and resource drained families

• Pile up of stressors and life circumstances

• Need active system support until we can re-build informal supports


60

Respectful and Culturally Mindful Engagement

• Appreciative perspective: Families are doing the best they can do, at any given time, given their current capacities and abilities, and life circumstances.

• Strengths and Culture Discovery (VanDenBerg): IHT providers strive to understand and appreciate the family’s values, culture, strengths, and life realities.

• Validation and Valuing: The youth and family are validated for their courage, efforts, and persistence, knowing that progress is sometimes very difficult, and that “hanging in there” is sometimes all that is possible at any given point in a family’s life. (Resiliency Ohio, 2008)


61

Partnering with Youth & Families

• The whole is greater than the sum of its parts. Working together accomplishes more than working apart

• We need to pool our resources and expertise

• Mutual Expertise: Youth and families are experts on their lives and you are an expert in your field.

• Engage parents and young adults in transition as co-consultants


62

IHT Lessons Learned: Engagement

• Mutual assessment process: youth and families are assessing us as we are assessing them

• Misinterpreting a family’s self protection as resistance

• Public testimony versus private testimony


63

Cross-system Collaboration and Advocacy

• Pro-active cross-system collaboration and service coordination

• Skillful advocacy efforts are promoted to assist with accommodations and system navigation - while respecting other child-serving system’s mandates


64

Supervisory Support, Availability and Team Consultation

• Access and availability for IHT staff when needed

• Pro-active consultation and strong clinical support

• Supervisor should have a designated responsibility to the team


65

Phases of Home-based InterventionEngagement and Assessment• Engagement (youth, family, & collaborative partners)• Risk Management and Safety Planning• Assessment

Treatment• Individual and family treatments and supports• Skill Building, Skill Consolidation, and Generalization

Enhancement of Positive Support Network • Linkages, Closure, & Follow-up

Discharge• In Ohio the average LOS for Intensive Home-Based Treatment is 4.5 months


66

Multidimensional Assessment

I. Diagnoses: youth who meet the criteria for Mental Health Disorder and related symptom manifestation

II. Developmental Functioning: (cognitive, emotional, & behavioral maturity)

III. Contextual Functioning: Individual functioning in relevant life domains, including risk and protective factors, and risk and recovery environments

IV. Safety Risks: Self and other harm, personal, family, and community safety


67

Comprehensive Array of Services:IHT Core Services

• Risk management and safety planning• Skill building• Individual & Family Interventions• Cross-System Interventions and Service

Coordination• Resource and support building activities


68

Organizational Framework

• Need framework for organizing the myriad of information obtained in the home environment

• A family need hierarchy is utilized to assist in assessing and prioritizing the youth’s and family needs

• Strategies and interventions are matched to the most salient need, progressing to more complex needs once the primary needs are met


69

FAMILY NEED HIERARCHY R. Shepler (1991;1999)

Recovery & Resiliency

ECOSYSTEMIC FUNCTIONING

BASIC SKILLS

BASIC NEEDS & SAFETY


70

Basic Needs, Safety, and Stabilization

• Are there material needs that are unmet? (Food; Shelter)

• Are there current safety and/or symptom concerns that need stabilization?

• Are there significant risk factors that are barriers to recovery?


71

Basic Needs and Safety (con.)

Assist with basic needs: Active Case Management and Advocacy

Establish basic safety: Risk management; safety planning; symptom stabilization

Risk reduction: Reduce risk factors and environmental stressors.


72

Basic Skills

• Does the youth and family know how to do what you are asking them to do?

• What skills does the youth need to be successful?


73

Skill Set Development

• Emotional regulation skills (CBT; DBT; ART; etc)

• Communication skills: individual and family

• Conflict management skills: Negotiation, compromise, problem solving skills: conflict resolution; mediation

• Self knowledge: Triggers; symptom management

• Personal safety skills


74

Ecosystemic Functioning

• What family or system dynamics are barriers to the youth and family’s success?

• How well does the youth function in key life domains/ (home, school, peers, community)

• Goal: Improve functioning in major life contexts (family, school, community, social, vocational, etc)


75

Family Context: Set Stage for Change

• Create family recovery environment • Decrease family conflicts• Rebuild bonds and relationships• Increase positive family communication • Increase supervision and monitoring


76

Community Context: Building Connections

• Educate community professionals (schools, juvenile court, children services, etc) on the impacts of mental health challenges

• Facilitate reasonable expectations

• Facilitate accommodations

• Facilitate connections and opportunities


77

Recovery and Resiliency• What resources and supports are necessary for ongoing

growth and development?

Empowered parents Supports: informal and formal; for youth and family Positive peers and activities Mentors Pro-social activities Positive connections (School; community) Opportunities to give back Services:

• Wraparound process: ICC• Possible step-down services: therapeutic mentoring• Medications; Psychiatrist


78

IHT Discharge

• When to discharge:– Presenting mental health symptoms no longer

causing functional impairments – Child no longer at-risk of placement– Safety issues are stabilized– Treatment gains have reached a plateau– Family voice and choice– Youth needs higher level of care for safety– Treatment plan goals have been met


79

Lessons Learned: IHT Discharge• Common Issues:

– Difficult for family to let go of valued service – Pressures from community to remain involved– No viable step-down options– Family crises at termination or as services wind down – There is still lots of work to do

• Keep in mind:– Medicaid pays for episodes of treatment– IHT is based on medical necessity and therefore is typically

time limited


80

Common Concerns and Challenges

• Bugs• Contagion• Animals• Weapons• Neighborhoods• Distractions: phones; TV; visitors

• Getting comfortable so you can do the work• Need to adopt standard safety precautions


81

Lessons Learned: Managing Challenges

• Remember you are a guest in family’s home• You are in control of the mental health service. The

family is in control of their home.• Be respectful of the family’s values and culture• Do not demand or challenge. Make simple request if

needed.• Relate to the family how the challenging situation

affects you and what would be helpful.


82

Lessons Learned from the Field

• Engagement is key • Confidentiality in the field• Reporting obligations• Where to do sessions• Transporting


83

Lessons Learned: Administrative Supervision

• Don’t let administrative supervision (productivity and paperwork) take time away for clinical supervision and case consultation time

• Managing caseloads and LOS

• Protecting electronic information– Client communications via internet– Texting

• Traveling with information

• Managing ethical situationsAll materials copyrighted 2009,

Richard Shepler, Ph.D

84

Lessons Learned: Implementation • Build policies that support the worker:

– Dedicated supervisor– Cell phones– Flex-time policies– Flex funds when possible– Adjusted productivity expectations – Policies and trainings that support worker safety , ethics,

and burnout

• Ongoing coaching and training• Supervisor with previous in-home experience is

criticalAll materials copyrighted 2009,

Richard Shepler, Ph.D

85

Lessons Learned: Implementation

• Clearly identify the target population and where your service fits into the overall continuum of care in your community

• What stakeholders need to be on board…who are the champions and what do they expect

• Significant community wide education about the program

• Be careful of the overpromise• Identifying and maintaining key referral sources• Plan and budget for turnover


86

The Critical Equation NIRN

Effective intervention practices and programs+Effective implementation practices=Good outcomes for children and their families

No other combination of factors reliably produces desired outcomes for children, families, and caregivers


87

Contact Information

• Rick Shepler, Ph.D., PCC-S 330-806-6976 [email protected]




BREAK!



Therapeutic Mentoring (TM)

Overview


Medical Necessity Criteria on MCE websites

Lauren Falls Network Health



Therapeutic Mentoring offers structured, one-to-one, strength-based support services between a therapeutic mentor and a youth for the purpose of addressing daily living, social, and communication needs.

Services are provided to youth (under the age of 21) in

any setting where the youth resides, such as the home and in other community settings such as school, child care centers, respite settings, and other culturally and linguistically appropriate community settings.



Therapeutic Mentoring Services are designed to:

Therapeutic Mentoring services include supporting, coaching, and training the youth in:

age-appropriate behaviors, interpersonal communication, problem-solving and conflict resolution, relating appropriately to other children and adolescents, as well

as adults, in recreational and social activities



Goal Directed

Therapeutic Mentoring interventions are designed to address one or more goals on a youth’s existing Outpatient or In-home Therapy treatment plan (for youth not in ICC), or on an existing ICP (for youth in ICC).

Progress toward meeting the identified goal(s) must be documented and reported regularly to the youth’s current treater(s).



Purposeful

The Therapeutic Mentoring provider engages the youth in community activities that meet one or more of the following purposes:Provision of anticipatory guidanceTeaching of alternative strategiesRole playingBehavioral rehearsalSkill acquisition in the community

Practicing skills in the communityExposure to social situations in which age-appropriate skills can be practicedEnhancing conflict resolution skillsDeveloping communication skills



Activity Based Interventions

Activity Based



Staffing Requirements

Minimum qualifications for Therapeutic Mentors include:21 years of age or older; and Bachelor’s degree in a human service field from an

accredited university and one (1) year experience working with children/adolescents/transition age youth; Associate’s degree in a human services field from an

accredited school and one (1) year of experience working with the target population; or High school diploma or GED and a minimum of two (2) years of experience working withchildren/adolescents /transition age youth




The Therapeutic Mentoring provider ensures that all Therapeutic Mentoring staff receive weekly individual supervision by a licensed clinician with specialized training in child/adolescent issues, child-serving agencies, mental health, family-centered treatment, strength-based interventions, and Wraparound planning process consistent with Systems of Care philosophy.

The Therapeutic Mentoring provider ensures that a senior licensed clinician is available for consultation within one (1) hour to Therapeutic Mentoring staff during all hours that Therapeutic Mentoring staff provide services to youth, including evenings and weekends.

97

Service, Community, and Collateral Linkages

Therapeutic Mentor works closely with the family, and any behavioral health existing/referring provider(s) to implement the goals and objectives identified by the referring provider.



The Therapeutic Mentor supports, coaches and trains the youth in order to support linkages to community resources and services that will sustain the youth’s optimal functioning in the community.

Youth



Process Specifications

Treatment Planning and Documentation

The referring provider is responsible for communicating the reasons for referral, and for identifying goals for Therapeutic Mentoring.

The Therapeutic Mentor:

contacts the family to initiate services within three (3) business days of receipt of the referral;has at least one contact per week with the youth’s ICC, In-Home Therapy Services, or outpatient provider to provide updates on progress toward goals on the identified treatment plan or ICP; ensures that all services are provided in a professional manner, ensuring privacy, safety, and respecting the youth and family’s dignity and right to choice;documents each contact in a progress report in the service record for the youth and shares this information with treatment team or CPT for youth in ICC;


September 9, 2009 100100

The Therapeutic Mentor:

must coordinate with the referring behavioral provider or ICC and attend all treatment team or CPT meetings that occur while they are providing Therapeutic Mentoring Services;

For youth in ICC, gives input to the CPT in order to clearly outline the goals of the service in the ICP and provide updates on the child/adolescent’s progress;

develops and identifies for the referring provider or CPT an anticipated schedule for meeting with the youth and a timeline for goal completion;

determines the appropriate number of hours per week/month for Therapeutic Mentoring services based on the needs of the youth as identified in the Treatment Plan or ICP.

Process SpecificationsTreatment Planning and Documentation (cont)


September 9, 2009 101101

Process SpecificationsDischarge Planning and Documentation

A discharge-planning meeting is initiated when the adult adolescent/ emancipated child, parent/caregiver and current treater or CPT for youth in ICC, determine that the youth has met his/her goals and no longer needs or meets the criteria for Therapeutic Mentoring Services.

The Therapeutic Mentor provider, in cooperation with the treatment team or CPT for youth in ICC, writes a discharge plan that includes reasons for discharge and documentation of ongoing strategies, supports, and resources to assist the youth and family in maintaining gains. The plan is given to the youth and/or parent/guardian/caregiver and, with consent, the existing behavioral health provider(s) within five (5) business days of the last date of service.

If unplanned termination of services occurs, the provider makes every effort to obtain the youth’s participation in the services and to provide assistance for appropriate follow-up plans. As a hub dependent service, the provider contacts the hub provider. Such activity is documented in the staff’s record for the youth.



Eligibility

Only: MassHealth Standard MassHealth CommonHealth



CSP

CSP services still available for youth under 21

TM and CSP have distinct but similar medical necessity criteria

Expected that one youth will not need both services at same time



TM Authorization Parameters

15 minute units

208 units in 90 days (13 weeks)


THERAPEUTIC MENTORING SERVICES

Teaching Skills to Navigate in the World

Marci White, MSW

NC Mentor

September 2009

CBHI Services Kickoff Meeting September 9, 2009

Therapeutic Mentoring Services – First Things First

Youth must be receiving Outpatient services, In-Home Therapy or ICC

Youth’s clinical condition requires the service to improve age-appropriate functioning or to ameliorate deficits in youth’s functioning

106


Therapeutic Mentoring: It has an “Assignment”

The service is needed to achieve specific goal(s) in the youth’s individual care plan (ICP) or treatment plan, including: Address daily living, social and communication needs Help the youth navigate social contexts, learn new skills and

make functional progress Support, coach and train age-appropriate behaviors,

interpersonal communication, problem-solving and conflict resolution, relating appropriately to others in recreational and social activities

107


“Assignment” (cont’d)

Teach skills through “structured, one-to-one support services” (across life domains and settings) in order for youth to remain at home, prevent out-of-home placement, or to transition “home”

Assist youth to communicate his/her needs to the Care Plan Team (CPT)/treatment team; contribute the “voice of the youth” in the youth’s absence

108


Therapeutic Mentoring Services –What It’s NOT

It is NOT observation or management during sport/physical activity, school, after-school activities, or recreation.

It is NOT a teacher’s aide. It is NOT for parental respite. The Therapeutic Mentor does NOT directly provide

social, educational, artistic, athletic, recreational or vocational services.

It is NOT a stand-alone service; it is part of the treatment plan developed by the youth’s clinical hub service (OP,IHT, ICC).

109


Therapeutic Mentoring – When?

For youth whose clinical condition and ability to manage stressors and feelings enable them to use supports and learn new skills for improved functioning in the community

Youth do not require significant or intensive behavior interventions or management in order to receive this service

110


What Does the Therapeutic Mentor Do? (One-to-one)

Teach alternative strategies Provide anticipatory guidance Role plays Behavior rehearsals Teach, enhance and practice conflict resolution

skills, problem-solving skills, and social skills in “everyday” social situations

111


What Else Does the Therapeutic Mentor Do?

Supervise youth’s practices of new and enhanced skills and engage the youth in discussions about effective strategies for handling “everyday” social situations

Help ensure the youth’s success in navigating various social contexts; give feedback; coach and support use of effective strategies

112


In What Kinds of Settings and Situations?

Social activities Recreational and athletic activities Artistic or creative activities Educational or vocational activities Activities of daily living In the youth’s home and in the community

113


Therapeutic Mentoring –Linkages and Connections

Participate on treatment/care plan team and inform other treatment providers of progress on assigned goal(s)

Assist the youth in communicating needs to the treatment/care plan team; provide the youth’s “voice” with the team in the youth’s absence

Support, coach and train the youth in connecting with existing and new treatment providers

Support, coach and train the youth in connecting with community resources and services that help sustain the youth’s optimal functioning in the community (natural supports)

114


Assess Progress Toward Goals

Describe the purpose of the contact and the goal being addressed

Describe the interventions, skill-building activities used with the youth; assess effectiveness of the intervention and describe youth’s level of mastery of the skill

Describe skill components or additional skills for which the youth still needs more practice

115


What does the Therapeutic Mentor need in order to start?

The “picture” of the youth and how he “works,” including: The skills and strategies the youth needs to address the

daily living, social and communication needs outlined in his/her plan

Youth’s strengths and interests (or protective factors) identified in the treatment plan

Additional protective factors the youth needs. Which ones would most likely help improve the youth’s functioning and address treatment goals?

116


Remember….

The Therapeutic Mentor carries out “assignments” from the treatment plan or care plan

The Therapeutic Mentor’s role is to help the youth learn skills to accommodate and function in the world, rather than to focus on getting the “world” to accommodate to the youth (other treatment services have that role)

117


“Begin with the End in Mind”

It is NOT a “forever” service Acquisition and demonstration of skills needed to

function more effectively in the community is the goal Transition from reliance on Therapeutic Mentor to use

of existing, natural supports in everyday situations If behaviors or needs require ongoing or long-term

support, other services may be more appropriate (or the goals needs to be re-evaluated and adjusted)

118


A Relationship With a Purpose and a Goal

“Kids can walk around trouble, if there is some place to walk

to, and someone to walk with.”

Tito, ex-gang member

119


Therapeutic vs Social Relationship Relationship

Structured and goal oriented

Focus on needs of youth Confidentiality mandated May or may not choose

staff

Spontaneous Focus on mutual benefit Confidentiality is by trust

only Choose your friends

120


Here’s some ideas for getting started!

Really listen and seek to understand Be honest Learn to apologize and forgive Show respect for the youth Make and keep promises Have a positive attitude Be kind Advocate Seek to understand the youth’s world Be consistent Keep your cool Use humor Maintain empathy Develop concrete goals

121


Structure for Teaching Skills

Directed and Intentional Observable Outcomes Evaluation and Feedback Provide Corrections Positive Reinforcers

122


Elements of Respectful Teaching

Give your full attention Identify teachable moments Act as a good model Treat people with respect Use appropriate body language Talk about the activity Confirm that learning is taking place

123


Model the Skill

People learn from watching other people; be a good model

When modeling a skill, refer to its components – name them.

Look for and create opportunities to model the skill with the youth (teachable moments).

Another youth, as well as the Therapeutic Mentor, can model skills.

124


Establish the Need for the Skill

Talk about reasons for learning the skill Give examples of benefits for the skill Give examples of consequences for not

knowing or using the skill

125


Negative behavior > Teach positive

Cursing, vulgar language

Being loud, boisterous

Sarcasm, whining, begging

Ignoring, defying rules/instructions

Easily drawn off task by disruptive

behaviors of others

Taking without asking

Hoarding stuff

Criticizing others, name-calling,

teasing

Avoiding eye contact

Use words appropriate for the setting

Use a voice level appropriate to the setting

Use an appropriate tone of voice for the setting

Teach how to and the benefit of following instructions

Ignore others’ behaviors Ask permission to borrow, touch

property of others Sharing Positive statements to

others/compliments Make good eye contact

126


Examples of Skills Youth Need and Can be Taught

Social Skills– Listening– Following instructions– Asking for help– Cooperating– Apologizing/expressing regrets

Problem-Solving Skills– Identifying the problem– Identifying options– Concentrating/Attention– Negotiation Skills– Evaluating outcomes

Daily Living Skills– Time management– Use of community resources– Job-seeking skills– Leisure skills/activities– Personal hygiene

Conflict Resolution Skills– Identifying differences– Respecting differences– Disagreement skills– Identifying anger triggers

127


Skills, Skills, Skills…..

Behavior Management Skills

• Identifying and expressing feelings

• Communication skills• Empathy skills• Handling group pressure• Dealing with fear• Avoiding trouble

Self-management Skills• Dealing with fear• Emotional regulation• Stress management• Identifying healthy options

for dealing with symptoms• Positive self-talk• Relaxation techniques• Expressing emotions

positively

128


Describe the Behavior Components of the Skill

Skills are made up of component behaviors “Following Instructions” is a skill; “Looking at the person” giving instructions is a

component of that skill

Define individual steps and components of a skill

Use behavioral terms that are observable when describing skill components

129


Basic Skill: Following Instructions

(+) Looks at the person Thinks about what is being

said Acknowledges the request;

asks for more information, if needed

Does the task immediately Checks back after completing

the task

(-) Looks away or rolls eyes Ignores instructions Delays beginning task Does not check back after

completing the task

130


Giving Effective Instructions 3 Essential Elements

Effective instructions are statements, not questions or suggestions. Unless you really are giving a choice, don’t frame it as a question.

Effective instructions are brief. One or two steps at a time is enough.

Effective instructions are clear, they state exactly what is expected.

131


Instructions That Often Don’t Work

Questions Buried Chain Repeated

Vague Distant “Let’s”

132


Behavior Rehearsals and Role Plays

A way to practice a new skill before youth tries to use it on their own

Role Play process:– Assign a specific role to the youth – Give guidance and feedback, including corrections– Role Play is “complete” when there are no more corrections – Use positive reinforcers – Discuss youth’s reaction to doing the role play

133


Practicing the Skill

Helps youth transfer learning to other settings Helps reinforce the skill as they begin using it. Lots of creative ways to practice – activities,

worksheets, art, diaries, charts, etc.

134


Prompting

Look for an appropriate teachable moment Use natural prompts Allow for time between prompts Use only brief vocal prompts Vary your tone of voice as appropriate Record required prompts

135


Independent Use of the Skill is the Objective

We want youth to use the skills on their own Using the skills will improve their functioning Families and friends become an active part of

the process Other people can help them learn and use the

skills Reinforcing skills in “everyday” situations helps

youth learn skills136


Continuation

Keep on keeping on….using those skills (what the Therapeutic Mentor can do to help):

– Summarize the skill components– Relate the skill to the youth’s treatment goals – Praise the youth’s use of the skill whenever you see it– Note the need/rationale for the skill– Acknowledge the challenges and stress the gains – Continue to model the skill– Remind youth to use the skill when needed– Ask the youth to tell you about using the skill since you last

met

137


References

Interpersonal Social Skills: Instructions for Teaching Social Skills to Consumers (NC Mentor, Raleigh, NC, part of The Mentor Network), Presented by Marci White, MSW, NC Mentor Raleigh, NC

Portions of this material adapted from the series of Ready-to-Use Social Skills and Activities for Pre-K, Grades 1-3, Grades 4-6, Grades 7-12, and Violence Prevention Skills, edited by Ruth Weltmann Begun

138



Lunch!

Back at 1:30pm



In-Home Behavioral Services (IHBS)

Overview


Medical Necessity Criteria on MCE websites

Briana Duffy Beacon Health Strategies for

Neighborhood Health Plan Fallon Community Health Plan


September 9, 2009 141141

In-Home Behavioral Services are delivered by one or more members of a team consisting of professional and paraprofessional staff trained in principles of behavior management, offering a combination of medically necessary

Behavior Management Therapy &Behavior Management Monitoring.

Services are provided in the youth’s home and community.

Components of IHBS


September 9, 2009 142142

Behavior Management Therapy Includes:a functional behavioral assessment,development of a highly specific behavior plan;supervision and coordination of interventions;

training other interveners to address specific behavioral

objectives or performance goals.

The behavior management therapist develops specific behavioral objectives and interventions that are designed to diminish, extinguish, or improve specific behaviors related to the youth’s behavioral health condition(s) and which are incorporated into the behavior plan and the risk management/safety plan.

Behavior Management Therapy


September 9, 2009 143143

Behavior Management Monitoring

This service includes:implementation of the behavior plan, monitoring the youth’s behavior, reinforcing implementation of the behavior plan by

the parent(s)/guardian(s)/caregiver(s), and reporting to the behavior management therapist on implementation and progress toward behavioral objectives or performance goals.

As a hub dependent service, the Behavior plan is designed to achieve a goal(s) identified in the youth’s ICC Individual Care Plan (ICP) or the treatment goals of the non-ICC hub.


September 9, 2009 144144

Behavior Management Therapy Activities

Behavioral Health assessment that includes the age appropriate version of the MA Child Adolescent Needs and Strengths (CANS) tool

Documented observations of the youth in the home and community

Structured interviews with the youth, family, and any identified collaterals about his/her behavior(s)

Completion of a written functional behavioral assessment

Development of a focused behavior plan that identifies specific behavioral and measurable objectives or performance goals and interventions that are designed to diminish, extinguish, or improve specific behaviors related to a youth’s mental health condition(s).


September 9, 2009 145145

Behavior Management Therapy Activities cont.

Development of specific behavioral objectives and interventions that are incorporated into the youth’s risk management/safety plan

Modeling for the parent/guardian/caregiver on how to implement strategies identified in the behavior management plan

Working closely with the behavior management monitor to ensure the behavior management and risk management/safety plans are implemented as developed, and to make any necessary adjustments to the plan.


September 9, 2009 146146

Behavior Management Monitoring Activities

Monitoring the youth’s progress on implementation of the goals of the behavior plan developed by the behavior management therapist

Providing coaching, support, and guidance to the parent/guardian/caregiver in implementing the plan

Working closely with the behavior management therapist to ensure the behavior management and risk management/ safety plans are implemented as developed, and reporting to the behavior management therapist if the youth is not achieving the goals and objectives set forth in the behavior management plan to permit modification of the plan as necessary.


September 9, 2009 147147

Minimum Staff Qualifications for Behavior Management Therapist

Master’s level (or above) clinician

Additional hours of coursework and training in conducting functional behavioral assessments and selecting, implementing, and evaluating intervention strategies.

Two (2) years relevant experience providing direct services to youth and families who require behavior management to address mental health needs.

Supervised experience conducting behavioral assessments and designing, implementing and monitoring behavior analysis programs for individuals.


September 9, 2009 148148

Minimum Staff Qualifications for Behavior Management Monitor

A bachelor’s degree in a human services field from an accredited university and one (1) year of direct relevant experience working with youth and families who require behavior management to address mental health needs,

OR

An associate’s degree and a minimum of two (2) years of relevant direct service experience working with youth and families who require behavior management to address mental health needs.



Additional requirements from last week’s alert

Behavior Management Therapist Board Certified Behavior Analyst (BCBA) Requirements at http://www.bacb.com

Behavior Management Monitors One year of direct ABA/Behavior Therapy

experience, under supervision of a BCBA, working with youth and families who require behavior management to address mental health needs.


September 9, 2009 150150


The In-Home Behavioral Services provider ensures that a licensed, senior clinician (master’s level or above), provides adequate supervision to professional and paraprofessional staff on a weekly basis.


September 9, 2009 151151

Service, Community, and Collateral Linkages

The In-Home Behavioral Services provider works collaboratively with ICC, In-Home Therapy Services, or other existing provider(s), and delivers services in accordance with the youth’s plan of care, and participates in all care planning meetings and processes.

The behavior management therapist completes a written functional behavioral assessment and develops a highly specific behavior plan with clearly defined interventions and measurable goals and outcomes within seven (7) days of the first meeting with the family.

In-Home Behavioral Services staff have contacts as needed but at least one (1) per week with the youth’s ICC care coordinator to provide updates on progress on the identified ICP goal(s).


September 9, 2009 152152

Discharge Planning and Documentation

A discharge planning meeting is scheduled whenever the authorized decision maker decides that services are no longer desired, or for youth in

ICC the CPT along with the family, determines that the youth has met his/her goals and

no longer needs the service, or the youth no longer meets the medical necessity criteria for In-Home Behavioral Services. The reasons for discharge and all behavior management treatment and discharge plans are clearly documented in the record.

The In-Home Behavioral Services staff develops an up-to-date copy of the behavior management plan, which is given to the parent/guardian/ caregiver on the last date of service, and to all current /referring provider(s) and/or to the ICC care coordinator and CPT within seven (7) calendar days of the last date of service.


September 9, 2009 153153

Discharge Planning and Documentation cont.

If an unplanned termination of services occurs, the provider makes every effort to contact the parent/guardian/caregiver to obtain their participation in In-Home Behavioral Services and to provide assistance for appropriate follow-up plans .

As a hub dependent service, the provider will make every effort to contact the hub provider. Such activity is documented in the record.



Eligibility

Only: MassHealth Standard MassHealth CommonHealth



IHBS Authorization Parameters

15 minute units

120 units in 30 days



September 9, 2009 156156

Placeholder for Mark’s slides


September 9, 2009 157157

BREAK!



Panel Discussion

Members Speakers for each service MassHealth MCEs

Moderator John H. Straus, M.D. Massachusetts Behavioral Health Partnership



Next Steps

Andrea Gewirtz Massachusetts Behavioral Health Partnership

Documents available at table outside: MCE specific authorization processes CBHI authorization parameters CBHI Service Definitions



Next Steps (Continued)

MCE network management teams

Regionally-based provider meetings

Send any questions to: [email protected] mailbox



Adjournment