intensive in-home services (iihs): aligning care ......understanding intensive in - home services...

Intensive In-Home Services (IIHS): Aligning Care Efficiencies with

Effective Treatment © BHM Healthcare Solutions 2013 1

Presentation Objectives

Attendees will have a thorough understanding of Intensive In-Home Services (IIHS) from an authorization perspective

Attendees will gain an understanding of the importance of Medical Necessity Criteria as it applies to IIHS

Attendees will learn key questions to ask through the authorization process

© BHM Healthcare Solutions 2013 2

Understanding Medical Necessity Criteria (MNC)

• According to a presentation by NC Department of Health and Human Services (Division of Medical Assistance)

• Medical necessity is individual but some generally accepted components are: • Intended to prevent, diagnose, correct, cure, alleviate, or preclude

deterioration of a diagnosable condition that threatens life, causes pain or suffering, or results in illness of infirmity

• Treatment is expected to improve the condition or levels of functions in relationship to the presenting diagnosis

© BHM Healthcare Solutions 2013

A clear cut definition does not exist.

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• According to a presentation by NC Department of Health and Human Services (Division of Medical Assistance)

• Medical Necessity • Essential and consistent with nationally acceptable standard of

practice • Reflective of a level of service that is safe, where not equally

effective, more conservative, and less costly treatment is available • Not primarily intended for the convenience of the person, family,

caretaker, or provider. It is not based upon availability of provider.

• Empathy does not equal medical necessity. • Is individualized, specific and consistent with the symptoms and

diagnosis • Is not in excess of the person’s needs

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• General Criteria Covered Medicaid shall cover procedures, products, and services related to this policy when they are medically necessary, and:


a. the procedure, product, or service is individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the beneficiary’s needs;

b. the procedure, product, or service can be safely furnished, and no equally effective and more conservative or less costly treatment is available statewide; and

c. the procedure, product, or service is furnished in a manner not primarily intended for the convenience of the beneficiary, the beneficiary’s caretaker, or the provider.

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Understanding Intensive In-Home Services (IIHS)

• The Intensive In-Home Service is a team approach designed to address the identified needs of children and adolescents who, due to serious and chronic symptoms of an emotional, behavioral, or substance use disorder, are unable to remain stable in the community without intensive interventions.

• This service may only be provided to members through age 20.



• This medically necessary service directly addresses the beneficiary’s mental health or substance-related diagnostic and clinical needs.

• The needs are evidenced by the presence of a diagnosable mental, behavioral, or emotional disturbance (as defined by DSM-IV-TR and its successors), with documentation of symptoms and effects reflected in the Comprehensive Clinical Assessment and the PCP.

• This team provides a variety of clinical rehabilitative interventions available 24 hours per day, 7 days per week, and 365 days per year.



This is a time-limited, intensive child and family intervention based on the clinical needs of the beneficiary. • The service is intended to accomplish the following:


reduce presenting psychiatric or

substance abuse symptoms,

provide first responder

intervention to diffuse current crisis,

ensure linkage to community services and resources, and

prevent out of home placement for the

beneficiary.

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• IIHS are authorized for one individual child in the family.

• The parent or caregiver must be an active participant in the treatment. • The team provides individualized services

that are developed in full partnership with the family.

• Effective engagement, including cultural sensitivity, is essential in providing services in the family’s living environment.

• Services are generally more intensive at the beginning of treatment and decrease over time as the beneficiary’s skills develop.



• IIHS are delivered to children and adolescents, primarily in their living environments, with a family focus, and include but are not limited to the following interventions as clinically indicated: • Individual and family therapy • Substance abuse treatment interventions • Developing and implementing a home-based behavioral support

plan with the beneficiary and the beneficiary’s caregivers • Psycho-education imparts information about the beneficiary’s

diagnosis, condition, and treatment to the beneficiary, family, caregivers, or other individuals involved with the beneficiary’s care.


Understanding Intensive Case Management

Intensive Case

Management includes the

following:

Assessment

Planning

Linkage and referral to paid

and natural supports

Monitoring and follow up

Arrangements for

psychological and psychiatric

evaluations

Crisis management


“First Responder” Crisis Response for IIHS

• The IIHS Team shall provide “first responder” crisis response, as indicated in the Person Centered Plan (PCP), 24 hours a day, 7 days a week, and 365 days a year to members of this service.

• In partnership with the beneficiary, the beneficiary’s family, and the legally responsible person, as appropriate, the Licensed or QP is responsible for convening the Child and Family Team, which is the vehicle for the person centered planning (PCP) process.


“First Responder” Crisis Response for IIHS

• The Licensed or QP is responsible for monitoring and documenting the status of the beneficiary’s progress and the effectiveness of the strategies and interventions outlined in the PCP.

• The Licensed or QP consults with identified medical (such as primary care and psychiatric) and non-medical providers (e.g., the county department of social services [DSS], school, the Department of Juvenile Justice and Delinquency Prevention [DJJDP]), engages community and natural supports, and includes their input in the person-centered planning process.


“First Responder” Crisis Response for IIHS Cont.

• IIHS also includes telephone time with the individual beneficiary and the beneficiary’s family or caregivers, as well as collateral contact with persons who assist the beneficiary in meeting the beneficiary’s rehabilitation goals specified in the PCP.

• IIHS includes participation and ongoing clinical involvement with the Child and Family Team and meetings for the planning, development, implementation, and revision of the beneficiary’s PCP.


Expectation of Services

• Program Requirements for IIHS members, all aspects of the delivery of this service occurring per date of service will equal one per diem event of a two hour minimum

• It is the expectation that service frequency will decrease over time: • at least 12 face-to-face contacts per beneficiary are required in the

first month, and at least 6 face-to face contacts per beneficiary per month are required in the second and third months of IIHS.

• The IIHS varies in intensity to meet the changing needs of members, families, and caregivers; to assist them in the home and community settings; and to provide a sufficient level of service as an alternative to the beneficiary’s need for a higher level of care.


Expectation of Services Cont.

• Services are delivered face-to-face with the beneficiary, family, and caregivers and in locations outside the agency’s facility.

• Each provider agency will assess and document at least annually the aggregate services delivered at each site using both of the following quality assurance benchmarks: • At least 60% of the contacts shall occur face-to-face with the

beneficiary, family, and caregivers. • The remaining units may be either telephone or collateral contacts. • At least 60% of staff time shall be spent working outside of the

agency’s facility, with or on behalf of the members.


Managing Care: IIHS Eligibility Criteria

• Some aspects of eligibility criteria such as diagnosis, frequency and severity of symptoms, and whether or not outpatient treatment has been attempted only need to be reviewed once at the beginning of the episode of care

• Other aspects of eligibility will need to be reviewed for each authorization, and additional authorizations including but not limited to: • Risk of out of home placement • Unmanageable in a traditional setting • The desired outcome or level of functioning has not been restored,

improved, or sustained over the time frame outlined in the beneficiary’s PCP



This criteria applies for everyone who receives this service • This needs to be reviewed for initial authorization, but

does not need to be reviewed for Continued Stay or additional authorizations


There is an Axis I or II MH/SA diagnosis (as defined by the DSM-IV-TR or its successors), other than a sole diagnosis of intellectual or developmental disability.

Yes; or No

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Is the current diagnosis supported with respect to the frequency and severity of symptoms?

Yes; or No

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Has outpatient treatment been attempted?

Yes; or No

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IIHS Eligibility Criteria Key Questions

• In regard to whether outpatient treatment has been attempted, the following questions should be asked: • If so, what happened? Is it well

documented? • Did parents or other caregivers

participate with that treatment? • If it was not attempted, why not? Is that

well documented? Is the rationale included in the assessment a component of the referral for IIH services?

• Could it be attempted now? Under what circumstances?


Managing Care: IIHS Eligibility Criteria Cont.

• The beneficiary has current or past history of symptoms or behaviors indicating the need for a crisis intervention as evidenced by suicidal or homicidal ideation, physical aggression toward others, self-injurious behavior, serious risk taking behavior (running away, sexual aggression, sexually reactive behavior, or substance use).

• For each authorization crisis situation information needs to be evaluated to determine if the consumer is still in a crisis situation (new and ongoing cases)



• In regard to whether the consumer is in a crisis situation, the following questions should be asked: • Is it truly a crisis or just an ongoing issue with

longer term problematic behavior? • Why is it a crisis now? • For new cases, what was happening 6

months ago when it was not a crisis? • Is this youth demonstrating signs of a

character disorder? (behaviors do have consequences)

• What techniques have been used in the past to deal with the symptoms?


IIHS Eligibility Criteria Key Questions (Cont.)

• In regard to whether the consumer is in a crisis situation, the following questions should be asked: • How have the caregivers typically responded?

Is there a way to modify that? • Has this member ever been inpatient? Is that

well documented? • Has this member been arrested? Is that well

documented? • Is the overall treatment history well

documented to support the need to call this a crisis?



This criteria applies for everyone who receives this service • This needs to be reviewed for each authorization


The beneficiary’s symptoms and behaviors are unmanageable at home, school, or in other community settings due to the

deterioration of the beneficiary’s mental health or substance abuse condition, requiring intensive, coordinated clinical interventions.

Yes; or No

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• In regard to unmanageable behavior, the following questions should be asked: • Why now? • What has caused this to occur? • What will it take to make it stop? • Could other less intrusive services

work? How do we know that? • Is this about bad parenting, poor

supervision, or is it typical adolescent behavior that does not require this level of intervention.



This criteria applies for everyone who receives this service • This needs to be reviewed for each authorization


The beneficiary is at imminent risk of out-of-home placement based on the beneficiary’s current mental health or substance abuse clinical symptomatology, or is currently in an out- of-home placement and a

return home is imminent.

Yes; or No

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Understanding “Imminent Risk”

• What is imminent risk?

• This does require that something be done. However, it does not have to be Intensive In Home Services. It really depends on what the clinical presentation shows, what is the diagnosis, the history of treatment, the parent or caregivers willingness to work on the issues etc.


“1. likely to occur at any moment; impending: Her death is imminent.”

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IIHS Eligibility Criteria: Understanding Alternatives

There is no evidence to support that alternative interventions would be equally or more effective, based on North Carolina community practice standards (Best Practice Guidelines of the American Academy of Child and Adolescent Psychiatry, American Psychiatric Association, American Society of Addiction Medicine). • This is especially important when determining when to

authorize this. There are many other services that could be attempted that many times were not.


Let’s discuss services that have been authorized in the past where other services may have helped.

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This criteria applies for everyone who receives this service • This needs to be reviewed for each authorization after

initial authorization


Continued Service Criteria The desired outcome or level of functioning has not been restored, improved, or sustained over the time frame outlined in the

beneficiary’s PCP; or the beneficiary continues to be at risk for out-of-home placement, based on current clinical assessment, history, and the tenuous

nature of the functional gains.

Yes; or No

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Additionally, one of the following applies (this is applicable to each authorization):


A. The beneficiary has achieved current PCP goals, and additional goals are

indicated as evidenced by documented symptoms.

B. The beneficiary is making satisfactory progress toward meeting goals and there is

documentation that supports that continuation of this service will be effective in addressing the goals outlined in the PCP.

C. The beneficiary is making some progress, but the specific interventions in

the PCP need to be modified so that greater gains, which are consistent with the

beneficiary's premorbid level of functioning, are possible.

D. The beneficiary fails to make progress, or demonstrates regression, in meeting goals

through the interventions outlined in the PCP. The beneficiary’s diagnosis should be reassessed to identify any unrecognized co-

occurring disorders, and interventions or treatment recommendations should be

revised based on the findings. This includes consideration of alternative or

additional services.

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Presenter

Presentation Notes

You do this every time you do an authorization


This criteria applies for everyone who receives this service • This needs to be reviewed for each authorization after

initial authorization


The desired outcome has occurred?

Yes; or No

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IIHS Eligibility Criteria

• The consumer discharge date, and discharge plan are crucial elements in mapping out the care plan

• Reviewers should view the discharge plan as the end goal of treatment and evaluate whether the level of care prescribed is furthering the discharge goal according to the timeline


ALWAYS ASK, “What is the estimated

discharge date and plan!”

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Discharge Criteria

Any one of the following applies:


A. The beneficiary has achieved goals and is no longer in need of IIH services.

B. The beneficiary’s level of functioning has improved with respect to the goals outlined in the PCP, inclusive of a transition plan to step

down to a lower level of care.

C. The beneficiary is not making progress or is regressing, and all

reasonable strategies and interventions have been exhausted, indicating a need

for more intensive services.

D. The beneficiary or legally responsible person no longer wishes to receive IIH services. E. The

beneficiary, based on presentation and failure to show improvement despite modifications in the PCP, requires a more appropriate best practice treatment

modality based on North Carolina community practice standards (for example, National Institute of

Drug Abuse, American Psychiatric Association).

Any one of the following applies

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• Other resources: • Medicaid Clinical Decision Support Tools

• http://www.ncdhhs.gov/dma/mp/index.htm

• EPSDT Information • http://www.ncdhhs.gov/dma/epsdt/index.htm

• IPRS Clinical Decision Support Tools • http://www.ncdhhs.gov/mhddsas/providers/servicedefs/index.htm


Question and Answer Session

http://www.ncdhhs.gov/dma/mp/index.htm

http://www.ncdhhs.gov/dma/epsdt/index.htm

http://www.ncdhhs.gov/mhddsas/providers/servicedefs/index.htm

More resources


Best Practice Clinical Practice Guidelines Links can be found on Eastpointe website under provider community/ Medicaid Utilization Review/ top three links on left hand side

Contact information

• Presented by:

• Lynnette Gordon, LPC, LCAS • UM director • Eastpointe LME/MCO • [email protected] • 910-298-7036


mailto:[email protected]

intensive in-home services (iihs): aligning care ......understanding intensive in - home services...

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