magellan health services, inc
TRANSCRIPT
Magellan Health Services, Inc.
Coordinated System of Care (CSoC)
Children’s Waiver
Provider Handbook Supplement
for the Louisiana Behavioral Health Partnership
APRIL 2014
Magellan Health Services, Inc.
Coordinated System of Care (CSoC) Severely Emotionally Disturbed (SED) Children’s Waiver Provider
Handbook Supplement
for the Louisiana Behavioral Health Partnership
Table of Contents
Section 1. Overview
Section 2. Waiver Administration and Operation
Section 3. Participant Access and Eligibility
Section 4. Referral Process to CSoC
Section 4a. Agency Specific Referral Processes
Section 4b. Re-Referral Process
Section 5. General Enrollment Process
Section 6. Participant Services
Section 6a. General Description
Section 6b. Parent Support and Training
Section 6c. Youth Support and Training
Section 6d. Independent Living/Skills Building
Section 6e. Short Term Respite
Section 6f. Crisis Stabilization
Section 7. Participant-Centered Planning and Service Delivery
Section 7a. The Wraparound Facilitator (WF)
Section 7b. The Family Support Organization (FSO)
Section 7c. Transfer Process
Section 8. Quality Assurance
Section 9. Restraints and Restrictive Interventions
Appendices
APPENDIX 1. Who Might the Coordinated System of Care (CSoC) Be Right For?
APPENDIX 2. Department of Children and Family Services (DCFS) Referral Process
APPENDIX 3. Office of Juvenile Justice (OJJ) Referral Process
APPENDIX 4. Department of Education (DOE) Referral Process
APPENDIX 5. Freedom of Choice (FOC) Form
APPENDIX 6. Child and Adolescent Needs and Strengths (CANS)
APPENDIX 7. Independent Behavioral Health Assessment (IBHA) or 1915(c) Form
APPENDIX 8. Department of Health and Hospitals Coordinated System of Care (CSoC)
Payment Guidance Document
APPENDIX 9. Description of Required Courses for WAA and FSO
Section 1. Overview
The Home- and Community-Based Services (HCBS) of the Coordinated System of Care are designed as
an approach to reduce out of home placement for qualifying youth. Established through a Medicaid
waiver plan, the goal is to divert from out-of-home placement through the provision of intensive home
and community-based supportive services.
The Coordinated System of Care (CSoC) provides to eligible youth and their families five waiver services
not available to other Medicaid youth. These services are: Independent Living/Skills Building, Short
Term Respite, Youth Support and Training, Parent Support and Training, and Crisis Stabilization. Youth
eligible for CSoC are between the ages of birth through 21.
CSoC services are administered by the Statewide Management Organization (SMO), Magellan Health
Services; and facilitated by the Wraparound Agencies. The five specialized CSoC services are provided
by community-based providers. The Office of Behavioral Health (OBH) contracts with Magellan to
review and authorize these waiver services.
The five waiver services can only be delivered by providers who are credentialed, enrolled and paid by
Magellan. The providers must meet both state licensing and HCBS provider requirements.
Source and supporting documentation used to create this handbook can be found in the federal
1915(c) and (b)(3) Home- and Community-Based Services (HCBS) SED Waiver and the Department of
Health and Hospitals Coordinated System of Care (CSoC) Payment Guidance document.
Section 2. Waiver Administration and Operation
Providers of waiver services are required to enroll with the State Management Organization, Magellan
Health Services, which will handle all applications, enrollment and credentialing. Refer to Magellan
Behavioral Health Provider Handbook Supplement for the Louisiana Behavioral Health Partnership
for credentialing, contracting, submission of claims, etc.
Local Wraparound Agencies will be the locus of treatment planning for the provision of these waiver
services. Wraparound Agencies are the care management agencies for the day-to-day operations of
the waiver in the parishes they serve. The Wraparound Agencies will contract with Magellan and are
responsible for the treatment planning of the programs.
Any provider, including the Family Support Organization, offering the five CSoC specialized services will
also be contracted with Magellan and will be responsible for adhering to the applicable guidelines.
Magellan is required to assure that the policies and procedures for the waiver are followed, as well as
to assure that quality services are provided. The Magellan Behavioral Health Provider Handbook
Supplement for the Louisiana Behavioral Health Partnership provides information on the Data
Collection Process, the Role of the Provider and Magellan, Review and Corrective Action Process,
Complaint and Grievance Process, Appeal Determinations, Background Check Requirements, etc. The
Department of Health and Hospitals Coordinated System of Care (CSoC) Payment Guidance document
establishes clear guidelines regarding retrospective administrative payments for CSoC including SMO
MSO administrative payments, the pass-through administrative payments to the Wraparound Agencies
(WAA), and payments for the five specialized waiver services (Appendix 8).
Section 3. Participant Access and Eligibility
Both clinical and financial criteria must be met to be eligible for the waiver. The clinical assessment is a
multi-step process. An initial brief screening (using the Louisiana Child and Adolescent Needs and
Strengths (CANS) Screen for CSoC Eligibility tool) is performed by the Care Manager at Magellan for
each child seeking services. If a child/youth screens positive, he/she is considered to be
“presumptively eligible” for CSoC and a referral is made to a Wraparound Agency (WAA). The WAA is
responsible for ensuring that the CANS Comprehensive Multisystem Assessment, the Independent
Behavioral Health Assessment (IBHA) form, and any other supporting documentation is gathered and
submitted to Magellan within thirty calendar days from the date of the written referral to the WAA.
Per the CSoC Payment Guidance document (Appendix 8), the child/youth is presumed to be eligible for
CSoC during this time, and is eligible to receive the 5 specialized waiver services (Parent Support and
Training, Youth Support and Training, Independent Living/Skills Building, Respite Care and Crisis
Stabilization). Administrative payments may also be paid to the SMO and WAA during this period
according to the Payment Guidance document. If upon completion of the assessment, the child is
determined to be ineligible, Presumptive Eligibility ends and all payments and services related to CSoC
must cease. If the child is determined to be eligible, the child/youth is to be enrolled in CSoC and
payments and services may continue. Appendix 1, titled Who Might the Coordinated System of Care
be Right for?, offers additional information on this topic.
Magellan is responsible for determining clinical eligibility upon review of the CANS Comprehensive, and
application of the CANS Decision Model algorithm, IBHA form and other pertinent documentation
(additional information supplied by the child, family, and wraparound facilitator).
Key considerations of clinical eligibility include:
• Must be between 0 and through the age of 21 years old;
• Lives, or for those in placement will be living, in a CSoC region which includes the following
parishes: Ascension, Avoyelles, Bienville, Bossier, Caddo, Caldwell, Catahoula, Claiborne,
Concordia, Desoto, Grant, East Baton Rouge (includes Zachary, City of Baker and Central
Community school systems), East Carroll, East Feliciana, Franklin, Iberville, Jackson, Jefferson,
LaSalle, Lincoln, Madison, Morehouse, Natchitoches, Orleans, Ouachita (includes City of
Monroe school system), Plaquemines, Pointe Coupee, Rapides, Red River, Richland, Sabine, St.
Bernard, Tensas, Union, Vernon, Webster, West Baton Rouge, West Carroll, West Feliciana, and
Winn;
• Has a DSM Axis I diagnosis or is exhibiting behaviors indicating that a diagnosis may exist
(Magellan will refer for a comprehensive assessment for diagnostic purposes);
• Meets clinical eligibility for CSoC as determined by the CANS scale which assesses the following
areas:
o Behavioral/Emotional Diagnosis or Behaviors, e.g. impulsiveness, anxiety, depression, history
of trauma, oppositional behavior, etc;
o Risky Behaviors, e.g. self-harming behaviors, aggression, fire setting, threats of harm to
others, etc;
o Difficulty functioning in various settings including family, home, school or community;
o Caregiver need for assistance with supervision, understanding behavioral health needs,
linking to appropriate supports and services, their own behavioral health needs, etc;
• Currently in an out of home placement (OOH), or at imminent risk of OOH placement;
• Often involved with multiple state agencies; and
• Identified family or adult resource that is or will be responsible for the care of the child/youth
that is willing to engage in wraparound.
Level of Care (LOC) and Level of Need (LON) are determined using the Child and Adolescent Needs and
Strengths (CANS) Comprehensive Multisystem Assessment Level of Care Decision Model in conjunction
with an Individual Behavioral Health Assessment (IBHA), also known as the 1915 (c) form or a bio-
psychosocial assessment. The CANS Comprehensive and IBHA form are completed by a physician
and/or a Licensed Mental Health Provider (LMHP) practicing under the scope of their licensure as
permitted under State law. Once these documents are completed they are forwarded to Magellan for
review by an independent evaluation team for final determination of clinical eligibility. A re-
assessment CANS and IBHA is completed at a minimum of every 180 days to verify continued eligibility
for services.
Financial eligibility is determined by DHH Medicaid eligibility workers.
Section 4. Referral Process to CSoC
CSoC referrals may be made to Magellan by calling in or by faxing a referral form. The General Referral
Process is as follows:
1. A call is made to Magellan at 1-800-424-4399 by the interested party.
2. The Member Service Representative (MSR) with Magellan will conduct a preliminary screening
by asking the caller the following three high risk questions, which will determine if the
child/youth meets the criteria to be referred for additional screening.
Over the past month:
a. Has the child ever talked about or actually tried to hurt him/herself or acted in a way
that might be dangerous to him/her such as reckless behaviors like riding on top of cars,
running away from home or promiscuity? Y/N/U
b. Has the child ever been a danger to others, such as threatening to kill or seriously injure
another person, fighting to the point of serious injury, been accused of being sexually
aggressive, or engaging in fire setting? Y/N/U
c. Has the child deliberately or purposefully behaved in a way that has gotten him/her in
trouble with the authorities such as breaking rules at school or laws in your community?
Y/N/U
3. If the questions asked by the MSR representative yields at least one “yes” response, then the
caller will be transferred to a Magellan Care Manager (CM) for additional screening.
4. The Care Manager (CM) will conduct the CANS Brief Screening. If the answer is “yes” to all four
domains on the CANS Brief, the child would be determined presumptively eligible.
5. If the child/youth is determined to be presumptively eligible, Magellan will submit a written
referral to the appropriate Wraparound Agency. Additionally, any immediate service need
identified can be referred to an appropriate provider right away.
6. If the child/youth is not determined presumptively eligible, Magellan will explore with the
caller, other LBHP services and resources that may be available.
Section 4a. Agency Specific Referral Processes
Specific referral processes for the Department of Children and Family Services, the Office of Juvenile
Justice and the Department of Education have been developed and are included in Appendices 2, 3,
and 4 respectively.
Section 4b. Re-Referral Process
The Freedom of Choice Form (FOC) (Appendix 5), the Child and Adolescent Needs and Strengths
(CANS) Comprehensive Assessment (Appendix 6), and the Independent Behavioral Health Assessment
(IBHA) (Appendix 7) must be completed within 30 calendar days from the date the referral was
received by the WAA. If, however, all documentation is not completed and submitted to Magellan
within the designated timeframe from the date the referral was received by the WAA, the following
steps should be taken:
1 - Disenroll the youth from your census
a. Send written notification to Magellan.
b. Send written notification to the referring source.
c. If the referring source was the Probation Office (PO) or Department of Children and
Family Services – Child Welfare section (DCFS- CW), then we strongly encourage you
to notify him/her that the youth is being disenrolled so he/she can ensure other
necessary supports remain in place and to update their care plan with the
child/family.
d. New referrals are only eligible for payment if the effective date of the new referral is
a minimum of 30 days from any previous referral. A new referral cannot originate
from the WAA (Appendix 8).
2 - Disenroll and encourage a Re-referral be made if your agency believes the youth and family
are possibly interested in participating in CSoC.
a. Encourage the parent/legal guardian/PO/DCFS-CW and/or the Provider to call a Re-
referral into Magellan at 1-800-434-4299 and ask to speak to a Care Manager (CM).
b. The caller can explain to the CM that this youth is being Re-referred to be screened
for CSoC services and that a CANS LA Brief has recently been done.
c. CM will be able to verify the youth’s information in Magellan’s computer system
and confirm that a CANS LA Brief has been done and confirm what date.
1. The date of the CANS Brief is within 30 calendar days of the original referral,
then Magellan’s CM will send the information to a Magellan CSoC CM and
proceed with a referral to the WAA/FSO in the appropriate region.
2. If the date of the CANS Brief is longer than 30 calendar days of the original
referral, then the CM will need to proceed like it is a new referral and conduct
another CANS Brief.
Section 5. General Enrollment Process
For the purposes of the Coordinated System of Care (CSoC), enrollment may be viewed as 3 distinct
processes.
CSoC Program Enrollment – Programmatic enrollment into CSoC occurs after the following
steps have been completed:
(1) Magellan sends a written referral to the Wraparound Agency (WAA), the Family Support
Organization (FSO) and a Certified Provider (CP). NOTE: The WAA may have LMHP staff
who serve as a CP;
(2) The parent/legal guardian signs the CSoC Freedom of Choice (FOC) document within 10
business days indicating acceptance of services through CSoC rather than services for
their child/youth in an institutional setting;
(3) The results of the CANS Comprehensive are reviewed by a Magellan independent
evaluator and clinical eligibility is determined based on scores and functional eligibility;
and
(4) Medicaid eligible children/youth have an active Medicaid waiver segment.
Medicaid Enrollment and Funding Stream Eligibility – At the time of the initial referral,
Magellan’s Member Service Representative (MSR) and/or Care Manager (CM) should determine
if the child/youth is currently enrolled in Medicaid. If the child/youth is not currently enrolled
in Medicaid, the WAA and FSO are notified that the family needs assistance with a Medicaid
application at the same time they receive the referral for CSoC from Magellan.
For information on the electronic enrollment site and locations of Medicaid enrollment centers
in Louisiana, go to http://new.dhh.louisiana.gov/index.cfm/page/220/n/20 or call the toll-free
Medicaid enrollment hotline at 1-888-342-6207 for assistance in completing the Medicaid
application.
Note: If the child/youth is not Medicaid eligible, another funding source must be
identified. A child/youth may be eligible for CSoC if a different funding source has been
identified. For non-Medicaid children referred to and enrolled in CSoC, referring
agencies must be billed. See Appendix 8 for the CSoC Payment Guidance (9-6-2013).
Waiver Enrollment – In order to be enrolled in a waiver, Magellan is required to submit a BHSF
142-BH form to the Louisiana State Medicaid Office. This electronic form is submitted by
Magellan indicating a child/youth meets the clinical criteria for the 1915 (c) waiver or the 1915
(b) waiver for b3 services. Once Magellan receives the completed CANS Comprehensive and
IBHA form for the child/youth and eligibility for CSoC is verified, Magellan submits the 142-BH
form to the Louisiana State Medicaid Office. The SMO must submit an updated 142 BH every 6
months following a reassessment, each time a child/youth transitions from one waiver to
another waiver, or when the child/youth is discharged from the CSoC program.
Freedom of Choice (FOC)
Upon receipt of a written referral from Magellan, the WAA is responsible for making the initial contact
with the child/youth’s family to provide information on CSoC and the specialized services available.
When possible, a member of the FSO staff goes on the visit with the WAA. During this initial visit, the
Wraparound Facilitator must ensure that the parent/legal guardian understands that they have the
option of accepting services through CSoC in their home and community or accepting behavioral health
services provided in an institution/hospital setting. If the parent/legal guardian is interested in
receiving behavioral health services for their child and family, they select their preferred placement,
either CSoC or Institution, and sign the CSoC Freedom of Choice form within 10 days indicating their
acceptance for services. At the same time, the parent/legal guardian is asked for their consent to
allow for the release of information between Magellan and the WAA by signing the Release of
Information section on the CSoC FOC. If the parent/legal guardian is not interested in receiving CSoC,
then the child/youth is not enrolled.
The CSoC Freedom of Choice form may be obtained at www.magellanoflouisiana.com. Go to
“Providers” and select “Forms” from the drop down menu.
Section 6. Participant Services
Section 6a. General Description
There are five specialized services that are available to children and families enrolled in CSoC. These
services are in addition to other services the family may be receiving. Refer to the Louisiana
Behavioral Health Partnership (LBHP) Service Definitions Manual at
http://new.dhh.louisiana.gov/assets/docs/BehavioralHealth/LBHP/ServicesManual-Current.pdf for a
full description of the CSoC Specialized Services. Chapter 1: Services for CSoC Children includes an in-
depth description of each service.
Section 6b. Parent Support and Training
This service connects families with people who are caregivers for children with similar
challenges. Parent Support staff provide assistance to families and help families develop skills. Parent
Support staff also provide information and education to families and help families connect with other
community providers.
Section 6c. Youth Support and Training
Young people who have been involved in behavioral health services or other child-serving systems in
the past provide support, mentoring, coaching and skill development to children and youth enrolled in
CSoC. This service works with the child or youth at home and in community locations. This service
helps the children and youth enrolled in CSoC to develop skills and abilities needed to overcome
challenges. Each child or youth in CSoC can receive up to 750 hours per calendar year.
Section 6d. Independent Living/Skills Building
This service helps children or youth who need assistance moving into adulthood. Children or youth
learn skills that help them in their home and community. Children or youth learn to be successful with
work, housing, school and community life.
Section 6e. Short Term Respite
Respite is designed to help meet the needs of the caregiver and the child. The respite provider cares
for the youth or child in the child's home or a community setting to give the caregiver/guardian a
break. Each child or youth in CSoC can receive up to 72 hours per episode with prior approval from the
SMO and a maximum of 300 hours of respite each year. This service helps to reduce stressful
situations. Respite may be planned or provided on an emergency basis.
Section 6f. Crisis Stabilization
This service provides response to crisis situations for a short period of time. It includes intensive
resources for the child or youth and his or her family. With this service, the child or youth is placed out
of the home for no more than seven (7) days per episode and no more than 30 days per year. This
service is meant to return the child or youth home after only a short stay away from home and to
prevent the child or youth from being admitted into a hospital.
Section 7. Participant-Centered Planning and Service Delivery
Wraparound is an intensive, individualized care planning and management process that is used to
achieve positive outcomes by providing a structured, creative and team-based planning process that
addresses the needs of the child/youth and their family. Wraparound is based on 4 key elements.
1) Grounded in a Strengths Perspective – Strengths of the family, team members, service providers
and community are used in all planning.
2) Driven by Underlying Needs – Identification of the underlying needs rather than the surface needs
leads to a better understanding of the causes of the behavior or situations.
3) Supported by an Effective Team Process – Understanding that a group of people working on a
common goal are more effective and achieve greater results than one person working alone.
4) Determined by Families – The family’s perspectives, opinions, and preferences are understood by
the team and play an integral role in the decision making process.
The Wraparound Agency (WAA) is responsible for ensuring the implementation of the wraparound
process in accordance with the wraparound principles and practice standards. The WAA staff, in
coordination with the Family Support Organization (FSO) staff, is responsible for guiding the family
through the wraparound process beginning at the point of referral through the transition out of
services provided by CSoC. During the first contacts with the family, WAA and FSO staff provides
information on the services that the child/youth and family may receive in CSoC. Staff is also
responsible for explaining the options for home/community based services, accepting behavioral
health services provided in an institution/hospital setting services/treatment, or declining services as
indicated via their signature on the Freedom of Choice form. The WAA is also responsible for ensuring
that all 1915 (c) HCBS Waiver requirements are met and that each child/youth that is enrolled in CSoC
has a current Child and Adolescent Needs and Strengths (CANS) Comprehensive Assessment and the
Independent Behavioral Health Assessment (IBHA) within the required timelines.
Section 7a. The Wraparound Facilitator (WF)
The wraparound facilitator (WF) is responsible for facilitating the wraparound process in accordance
with the wraparound principles and practice standards, and working with the family throughout their
participation in CSoC (See Appendix 9 for core training descriptions for Wraparound Facilitators). The
WF is one of the first contacts the family has after being referred to CSoC. The WF is responsible for
explaining the CSoC program, the wraparound approach and the five waiver services available for
youth and families enrolled in CSoC. It is also the WF’s responsibility to obtain the parent/legal
guardians signature on the Freedom of Choice form. Other responsibilities of the WF included, but are
not limited to:
• Meeting with the child/youth/family to complete the family story;
• Assisting the family in identifying and developing a Family Vision, Goals, Strengths, etc;
• Assisting the child/youth/family in identifying potential members of the Child and Family Team
(CFT);
• Convening and facilitating the CFT meetings (At a minimum CFT meetings are held monthly.
Additional meetings are held as needed in times of crisis); and
• Facilitating the development and implementation of the Plan of Care (POC), including the Crisis
Plan.
It is important for the WF to ensure that all plans and decisions are made by the CFT and are not made
independent of the team. (Refer to: 1915 (c) HCBS Waiver Appendix C for the five CSoC specialized
service provisions).
Section 7b. The Family Support Organization (FSO)
The FSO provides: 1) Parent Support and Training, and 2) Youth Support and Training for
children/youth enrolled in CSoC (See Appendix 9 for core training descriptions for Youth and Parent
Support Specialists). Services shall be delivered face-to-face with the majority occurring in community
locations. Services may be provided on an individual basis or in a group setting.
Responsibilities of the FSO include but are not limited to:
• Ensure appropriate screening, hiring, training processes are in place for each FSO staff person;
• Develop a cadre of Parent Support and Training (PST) and Youth Support and Training (YST)
staff in each region;
• Establish a centralized intake process for all requests for FSO services;
• Receive referrals for FSO services (PST/YST) from the State Management Organization or the
WAA when immediate and routine needs are identified;
• Attend Child and Family Team meetings as requested by the families receiving FSO services;
• Provide PST/YST services in accordance with the family’s Plan of Care;
• Participate in the Statewide Coordinating Council;
• Develop active partnerships and effective working relationships with all WAA staff;
• Actively partner with State and regionally-based WAA staff to promote the values of CSoC and
the value of WAA and FSO services; and
• Participate in the CSoC regional leadership groups including the Community Team.
(Refer to: 1915 (c) HCBS Waiver Appendix C for the five CSoC specialized services).
Section 7c. Transfer Process
In the event that a child/youth transfers/moves from one implementing region to another the referring
WAA and the new WAA have several responsibilities.
The referring WAA is responsible for:
• Notifying the WAA agency in the region where the child/youth/family will be moving;
• Obtaining signature to release information, such as the current POC and Crisis plan, and other
documentation related to the family to the WAA in the region where the child/youth/family will be
moving;
• Ensuring that the child/youth/family have the needed contact information for the new WAA
agency;
• Notifying Magellan immediately so new referral can be sent to new WAA. (Child/youth’s name and
other pertinent information will be added to new WAA roster; authorizations will be set up);
• Removing child/youth’s name from roster at his/her appropriate date and submitting a discharge
notice to Magellan that includes details about transition plan to the new WAA;
• Reviewing the existing POC and Crisis Plan and making any necessary changes with input from the
Child and Family Team; and
• Submitting revised POC and Crisis Plan to Magellan.
The new or referring WAA (the WAA in the region where the child/youth/family is relocating) is
responsible for the following:
• Obtaining parent/legal guardian signature on a new Freedom of Choice (FOC);
• Submitting signed FOC to Magellan;
• Reviewing the current POC and Crisis Plan and updating as needed with participation of members
of the CFT;
• Submitting new POC/Crisis plan to Magellan within 30 days of referral date;
• Assisting family in the identification of possible members for the CFT; and
• Ensuring that child/youth is placed on their roster.
NOTE: In the event that this transition to a different WAA occurs at the time that a new CANS
Comprehensive assessment and IBHA forms are required (i.e. at 180 days), then the existing WAA, the
agency that was working with the child/youth previously, will be responsible for completing the CANS
Comprehensive assessment and IBHA forms and submitting them to Magellan.
Section 8. Quality Assurance
Quality assurance (QA) is a set of activities intended to ensure that services meet certain standards and
that regulations are fulfilled. This includes intentional attention to continuous quality improvement
(CQI) where information is used to support and guide system improvement. These activities focus on
improving the CSoC process, improving individuals’ and families’ clinical/functional outcomes and
improving statewide system outcomes. This includes structured training and coaching to assure
fidelity to wraparound practice, participation in the Wraparound Fidelity Assessment System (WFAS),
as well as data collection to measure outcomes.
For more information about the measures of the WFAS, visit the website of the Wraparound
Evaluation and Research Team (WERT), at the University of Washington or at the following link:
http://depts.washington.edu/wrapeval/docs/wfas_FAQs_hotlink.pdf.
Information is shared with key partners as part of the CSoC QA process. The CQI and QA monitoring
functions and structures are continuously in development and will be refined as part of an ongoing
process.
Section 9. Restraints and Restrictive Interventions
Licensed enrolled providers of waiver services are prohibited by licensing regulations to inflict corporal
punishment, use chemical restraints, psychological abuse, verbal abuse, seclusion, forced exercise,
mechanical restraints, any procedure which denies food, drink, or use of restroom facilities and any
cruel, severe, unusual or unnecessary punishment.
The only restraint that may be used in an emergency is a protective hold which is the application of
body pressure to an individual for the purpose of restricting or suppressing the person’s movement.
Protective holds are only to be used in an emergency to prevent a person from causing harm to self or
others and after other, less restrictive interventions/strategies have failed. Protective holds may only
be implemented by trained staff and of short duration. [Louisiana Revised Statutes 40.2006(E)(2) &
40.2120.11-40:2120.16 which cover the broad range of agencies, programs, and facilities that are
subject to the Statutes].
Enrolled providers of waiver services are required by licensing regulations to ensure that non-intrusive,
positive approaches to address the meaning/origin of behaviors that could potentially cause harm to
self or others are utilized.
Direct care staff are required to have initial and annual training in the management of aggressive
behavior, including acceptable and prohibited responses, crisis de-escalation, and safe methods for
protecting the person and staff, including techniques for physically holding a person if necessary.
When a participant becomes angry, verbally aggressive or highly excitable, staff will utilize this training.
If a protective hold must be utilized, direct care staff will write a Critical Incident Report, and follow
appropriate procedures for reporting to Magellan.
The Wraparound Facilitator will contact the participant and his/her legal representatives within 24
hours of receiving the incident report involving a protective hold. Changes to the service plan or living
situation will be considered to support the person’s safety and well-being. Follow-up visits in response
to the Critical Incident Reports and complaints with the participant and his/her legal representative are
conducted and include questions about any actions taken by a service provider that may qualify as
unauthorized use or misapplication of physical restraints.
Unauthorized, over use or inappropriate use of protective hold is detected through the annual SMO
monitoring approved by OBH. The SMO and OBH will ensure that all applicable state requirements
have been followed regarding restrictive intervention as part of the Critical Incident report review
process.
APPENDIX 1
Who Might the Coordinated System of Care (CSoC) be Right For?
A child/youth eligible for CSoC will meet the following criteria:
1. Twenty-one (21) years old or under
2. Lives, or for those in placement will be living, in a CSoC region which includes the following parishes:
Ascension (CMS Approval 9/13), Avoyelles, Bienville, Bossier, Caddo, Caldwell, Catahoula, Claiborne,
Concordia, DeSoto, Grant, East Baton Rouge (includes Zachary, City of Baker and Central Community school
systems), East Carroll, East Feliciana, Franklin, Iberville, Jackson, Jefferson, LaSalle, Lincoln, Madison,
Morehouse, Natchitoches, Orleans(CMS Approval 7/13) , Ouachita (includes City of Monroe school system),
Plaquemines (CMS Approval 7/13), Pointe Coupee, Rapides, Red River, Richland, Sabine, St. Bernard (CMS
Approval 7/13), Tensas, Union, Vernon, Webster, West Baton Rouge, West Carroll, West Feliciana, and
Winn.
3. Has a DSM Axis I diagnosis or is exhibiting behaviors indicating that a diagnosis may exist (Magellan will refer
for a comprehensive assessment in order to make an eligibility determination).
4. Meets clinical eligibility for CSoC as determined by the Child, Adolescent Needs and Strengths (CANS) scale
which assesses the following areas:
a. Behavioral/Emotional Diagnosis or Behaviors, e.g. impulsiveness, anxiety, depression, history of trauma,
oppositional behavior, etc.
b. Risky Behaviors, e.g. self-harming behaviors, aggression, fire setting, threats of harm to others, etc.
c. Difficulty functioning in various settings including family, home, school or community.
d. Caregiver need for assistance with supervision, understanding behavioral health needs, linking to
appropriate supports and services, their own behavioral health needs, etc.
5. Currently in an out of home placement (OOH), or at imminent risk of OOH placement in these settings:
Psychiatric Hospitals Foster Care
Psychiatric Residential Treatment Facilities Therapeutic Foster Care
Therapeutic Group Home Developmental Disabilities Facilities
Non-medical Group Home Alternative Schools
Addiction Facilities Secure Care Facilities
Detention Homeless (as identified by the Department of Ed)
6. Generally involved with multiple state agencies.
7. Identified family or adult resource that is or will be responsible for the care of the child/youth that is willing
to engage in wraparound.
8. Eligible for Medicaid or deemed eligible for Medicaid based on clinical need. (Certain children/youth not
typically eligible for Medicaid may be eligible based on clinical need.)
Other Considerations:
• If a youth is in the custody of the Office of Juvenile Justice (OJJ), referral to CSoC will be made when the
anticipated discharge is known and is within 90 days (for youth in a non-secure residential setting) or 30
days (for youth in a secure care center).
• If a child is in the custody of the Department of Children & Family Services (DCFS), referral to CSoC will be
made when transition date from a restrictive environment is known and is within 60 days.
• A child/youth currently receiving Multi-Systemic Therapy (MST) or Functional Family Therapy (FFT) cannot
concurrently be enrolled in CSoC. NOTE: As of 2-20-14, a child/youth may be concurrently enrolled in CSoC
and FFT.
• If a child screens eligible for CSoC based on the CANS and does not live in a CSoC region, then the family will
be contacted by a Magellan Resiliency Care Manager who will provide intensive individualized care
management.
To determine if a child/youth may be appropriate for the Coordinated System of Care (CSoC) or for more
information, anyone may contact Magellan at 1-800-424-4399.
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APPENDIX 2
Department of Children and Family Services (DCFS) Referral Process
How to Make Referrals to LBHP
1) Medicaid Eligible Clients:
Once the BH1 or BH2 indicates the need for referral, clients can be linked to the appropriate services.
There are two ways to link Medicaid eligible individuals to services:
o Direct Referral – This process can be utilized for any behavioral health service. This type of referral
is secured through direct contact with a Magellan provider. When contact is made to the provider,
staff shall inform the provider of the reason for the referral and that the client is Medicaid eligible.
Staff shall follow up the call to the provider with an entry into Clinical Advisor (CA). In CA, staff will
enter demographic information and the reason for the referral (i.e. outpatient therapy,
assessment, IHBS, etc.). There is no TIPS entry necessary with a Medicaid eligible client referral. The
CA entry links the referral to DCFS for tracking.
Note: Referrals to IHBS shall be made in the child’s name in order to be covered by Medicaid. In
addition, a child cannot be enrolled in CSoC and MST at the same time.
o Call to Magellan Member Services – If a referral is made for CSoC eligibility or if the DCFS worker
does not know what services a client may need, a call to the Magellan Member Services call center
at 1-800-424-4399 is warranted. Prior to calling Magellan to make a CSoC referral, staff must enter
CA and endorse CSoC on the DCFS Recommended Services page. It is critical in any referral that
DCFS staff presents all necessary clinical information on the case so an effective referral can be
made. If Behavioral Health services are identified as necessary in this call, the Care Manager will
give DCFS staff the names and phone numbers of providers and DCFS is responsible for setting up
an appointment for the client with an approved provider. After the provider is contacted, staff will
enter demographic information and the reason for the referral (i.e. outpatient therapy, 90801
assessment, IHBS, etc.) into CA. No TIPS entries are necessary with a Medicaid eligible client
referral.
2) Non Medicaid Clients:
Children not eligible for Medicaid will be provided with behavioral health services as needed either through
the LBHP or outside of the system (as budget allows).
17
APPENDIX 3
Office of Juvenile Justice Referral Process
Referral from an OJJ Probation Officer (PO):
1. The PO’s referral information includes: reason for referral, demographic information and referral date
documented in Clinical Advisor (CA) and if available, any clinical information the PO may have on the
child. Magellan Care Manager (CM) will initiate the process of authorizing a child for services only upon
OJJ PO entering a referral into Clinical Advisor. In the event of an emergency, OJJ may also directly
refer to a NMG (basic group home sub-type) for up to 30 days without an authorization from Magellan.
2. OJJ’s PO may call the provider directly with the referral (who would then call Magellan for
authorization, if needed) or the PO may call Magellan to discuss and/or inform the Care Manager of
referral. If the PO calls the provider directly, then see “Referral from a Provider” below for more
details.
3. When the PO calls Magellan, the PO asks the Member Service Representative (MSR) to connect them
to an available Magellan’s OJJ-designated Care Manager (CM).
4. The PO explains if the referral is for a “needs assessment,” “placement” or other reason. Magellan is
required to administer a CANS brief screen for all children to see if they may qualify for CSoC. (Note:
The CANS Brief screen is utilized to assist in determining CSoC eligibility and is not used for the purpose
of determining level of care placement or regarding specific services). If the CANS Brief screen has not
been done for the child, the CM will administer it unless the family /OJJ is not interested in CSoC
services. If CSoC services are not wanted, then the CANS Brief screen will not be done. If CSoC is
desired, then the CM will administer it with the PO if the PO has the appropriate information. If the PO
does not have sufficient information, the CM will determine from the PO who would be the most
appropriate person to contact. If the CANS Brief screen is positive, CM will make concurrent referrals to
a CP (to determine CSoC eligibility), a WAA and a FSO to collaboratively develop a POC with the child
and identified supports.
a. A needs assessment refers to a request for Magellan’s assistance in knowing what services or
what type of provider will be in the best interest of the child. The PO does not need to call for
all referrals; only if Magellan assistance is needed. Most often Magellan would then refer to an
LMHP to do a 90805 to determine treatment needs. Based on information from the PO and the
needs of the child, the CM may refer to a psychiatrist, psychologist, social worker or other
professional. Names and phone numbers of appropriate providers will be given to the PO, who
may call to set up an appointment. An authorization number is provided to the provider, not to
OJJ or the member.
b. A placement request is when the PO wants Magellan’s help in locating a bed or provider. In
this situation, if the PO has enough information to believe a certain LOC is warranted, the
Magellan CM will do a service authorization review to determine medical necessity with the PO
to make sure it meets service authorization criteria for the level of care being requested. If it
does, the CM will assist the PO in locating the desired provider. CM will document this
information into the Magellan’s clinical documentation system in the event another CM takes a
call from the receiving provider. An authorization determination is made with the PO so it is
known if a referral to that level of care is warranted (this avoids a referral and then a denial). If
the PO does not have sufficient clinical information to make an authorization decision, then a
referral to a provider may be made in order to get the necessary clinical information.
18
5. As a reminder, the PO does not need to call Magellan in the following situations:
a. The PO has a specific provider he/she would like to refer the child or adult to. The provider then
would call Magellan for authorization, if needed;
b. For placement at a NMGH;
c. A referral to a psychiatrist for medication management; and,
d. A referral for Psychological Testing (Psychologists complete and fax a Request for Psychological
Testing Form to Magellan)
Referral from a Provider:
1. If a provider contacts Magellan directly requesting authorization, Magellan will confirm if the child is
Medicaid or non-Medicaid.
a. If the child is non-Medicaid, Magellan CM will look in Clinical Advisor (CA) to see if there is a
referral from OJJ. If there is a referral, the CM will perform a service authorization criteria review
and authorizes care if criteria are met. If there is a change in the child’s clinical status, Magellan
will communicate that information to the OJJ PO listed in CA. If there is not a referral in CA, the CM
will confer with the designated OJJ contact staff member to determine if OJJ will refer the child to
the requested service.
b. If the child is Medicaid, then Magellan will perform a service authorization criteria review and
authorize care if criteria are met. If there is a change in a child’s clinical status, Magellan will
communicate that information to the OJJ PO listed in the referral or to the designated OJJ contact
staff member if there is no referral. OJJ then may follow up with the provider regarding the
treatment plan.
2. For inpatient emergency admissions, if the child is Medicaid, Magellan will follow standard procedures
for authorizing services based on meeting service authorization criteria. For non-Medicaid children,
Magellan looks in CA to see if OJJ has custody. If yes, then Magellan does a review and authorizes
according to the service authorization criteria. If not, Magellan will inform the ER/hospital that it will
track the admission and discharge, but is not able to authorize service. Magellan will inform OJJ of any
hospital admissions.
3. For outpatient services, if the child has Medicaid, Magellan will authorize access up to 24 outpatient
psychotherapy sessions and 12 medication management sessions. For non-Medicaid children, there
must be a referral in Clinical Advisor. If there is a referral, Magellan CM will authorize access up to a
total of 24 outpatient psychotherapy and/or 12 medication management sessions. Additional sessions
require prior authorization. Without a referral, the provider will not be reimbursed for services.
Referral from a Child/Youth or Family Member (Legal Guardian):
1. If a child/youth or family member contacts Magellan seeking services, Magellan will confirm if the child
is Medicaid or non-Medicaid.
a. If the child is non-Medicaid, Magellan will look in CA to see if there is a referral from OJJ. If there is
a referral, the CM will conduct a service authorization criteria review and authorize services if
criteria are met. If there is not a referral in CA, the CM will confer with OJJ to determine if OJJ will
refer the child.
b. If the child is Medicaid, Magellan will follow standard referral procedures. If there is a change in a
child’s clinical status, Magellan will communicate that information to the OJJ PO listed in the
referral or to the OJJ Statewide liaison if there is no referral. OJJ then may follow up with the
provider regarding the treatment plan. (Revised 3/4/14)
APPENDIX 4
Department of Education (DOE) / Local Education Agencies (LEAs) Referral Process
Referrals by Schools to the Coordinated System of Care (CSoC)
Eligibility Criteria:
“Who Might the Coordinated System of Care (CSoC) be Right For?” (See APPENDIX 1 of this document.)
Who should be referred?
Students enrolled in general or special education classes that have significant behavior problems and have one or
more of the following:
1. Are continually being removed from or at-risk of being removed from the regular class setting due to significant
behavior issues and are sent to in-school or out-of-school suspension;
2. Are at-risk of being removed from or have been removed from their home school setting due to behavior
issues/substance abuse issues and are placed in an alternative school/program;
3. Are involved with multiple state agencies;
4. Are identified as Tier 3 students in the PBIS schools;
5. Are receiving behavioral health services through a current IEP, regardless of exceptionality/ies; and/or
6. Are identified as ‘homeless’ under the definition of the DOE.
Information Needed when Making a Referral 1. Obtain parental consent in accordance with the district’s policy
2. Have the following information on the student ready:
a. Correct spelling of first/last name
b. Birthdate
c. Gender/Race
d. Medicaid #, if available
e. Medical/Psychiatric Diagnosis, if appropriate
f. If the student has a current IEP, the student’s
exceptionality/ies and behavioral health services
are on the IEP;
g. Parent/Guardian name
h. Home address
i. Telephone numbers (home, work, &/or cell)
j. Other state agencies involved in student’s life
(court system or foster care)
k. Student’s current living setting such as family
home, other family members, foster home,
group home, etc.
Referral Steps 1. Call Magellan 1-800-424-4399.
2. First Contact will be with Member Service Representative (MSR) and will take approximately 5-10
minutes.
3. Say that you are from a school and you are seeking additional behavioral health services which might
include CSoC.
4. MSR will need the following:
a. Basic identifying/demographic information listed under “Information Needed.”
b. Responses to 3 questions:
i. Is the student suicidal? Is the student threatening to hurt himself?
ii. Is the student threatening to hurt his family, friends, others?
iii. Is the student breaking rules in the home, school or is involved in the court system?
5. MSR will forward caller to Care Manager and caller will be placed in the clinical queue. (if answer is
“yes” to any of the three questions above)
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The average speed of answer for the clinical queue is approximately one to two minutes; however,
depending on the volume of calls, wait times may be longer (especially during peak call time).
6. Magellan does not have a voicemail option once the call is placed into the call queue. You will remain
on the line until the call is either answered by a care manager or you hang up.
7. The option of going back into the queue is available for callers, who for whatever reason, did not
connect to a care manager upon begin transferred by the MSR. When calling back 1-800-424-4399,
ask to be placed back in the call queue. (Be sure to advise the MSR that you already have a case in the
queue.) The MSR will locate the prior transaction to confirm that a case was built and will transfer you
to the appropriate queue.
8. Care Manager will verify information given to MSR and will ask questions about the following:
Crisis Intervention
i. Is the student suicidal?
ii. Is the student threatening physical harm to others?
b. Relationships with Family
i. History of problems with family
ii. History of running away
iii. Discipline issues at home
c. Relationships at School
i. Problems making/keeping friends
ii. Current peer group
iii. Bullies others or is the target of bullies
d. Emotional
i. Easy to anger/frequent anger outbursts
ii. Depression/withdrawal from family, peers, and/or others
iii. Fighting at home, school, and/or community
iv. Anxious, easily upset
e. Sexual issues
i. History sexual abuse
ii. Sexual acting out
iii. Pregnancies
f. Medical History
i. Physical health diagnosis/concerns
ii. Behavioral health diagnosis
iii. Substance Abuse
g. School History
i. School truancy
ii. School delinquency
iii. Suspensions/expulsions due to behavior problems
iv. Poor academic performance or history of learning problems
h. Legal issues
i. History of legal problems such as stealing, reckless driving, substance abuse, etc.
ii. Probation or placement in detention center
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APPENDIX 5
FREEDOM OF CHOICE FORM
LONG TERM CARE/CHOICE OF SERVICES - Coordinated System of Care (CSoC)/SED Children
Section I Identifying Information
Recipient/Child’s Name: ________________________ Date of Birth: _______________________
Physical Address: _______________________ City: ______________________________
State: ________ Zip Code: ________ Telephone Number: (____) ____-_______
Social Security Number: _________________ Medicaid Number: __________________
Recipient currently resides in: Family Home Group Home Nursing Home Developmental Center/ICF
(Circle One) Psychiatric Hospital
Name of Facility if Applicable: ___________________________
Section II Freedom of Choice
I understand that I have a choice in accepting CSOC Services or placement in an institution. CSoC and
institutional services have been explained to me.
I would like to receive: (Circle One) CSoC Waiver Services Institutional Services
___________________________________ Date: _____________________________
Signature of Recipient/Legal Guardian or Custodian
Section III Release of Information
I permit the release of any and all information pertaining to my application for services, which may be in the
possession of the Wraparound Agency (WAA), to Magellan Health Services of Louisiana. The release of
information includes, but is not limited to, my individualized Plan of Care, progress notes, doctor’s
reports/evaluations, psychological reports/evaluations, medical/social/educational assessments, including
those provided by schools, other agencies, and or organizations, including all third party information which
may be in DHH’s possession. In the event that this form is signed by the Department of Children and Family
Services (DCFS), the information released is confidential pursuant to state and federal law including but not
limited to Louisiana Revised Statute 46:56. The use of this information shall be limited to the purpose of
providing behavioral health services to the above named child.
_______________________________________ Date: _____________________________
Signature of Recipient/Legal Guardian or Custodian
_______________________________________
Relationship to Recipient
BHSF Form LTC/CS 1203
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APPENDIX 6
23
APPENDIX 7 1915(c) INDEPENDENT BEHAVIORAL HEALTH ASSESSMENT
BEHAVIORAL HEALTH HISTORY
DEMOGRAPHIC INFORMATION
Child/Youth Name: (first, middle, last) Assessment Date:
Age: DOB: Ethnicity: Gender: Gender Expression: SSN:
Parent/Primary Caretaker Name: (first, middle, last) Is this person, the legal guardian?
□ Yes □ No (if not, enter information below)
Legal Guardian Name: (first, middle, last) Title/Department: Phone Number:
I. CHIEF COMPLAINT (Major symptoms, difficulties, and/or Issues as they relate to behavioral health –in client/members’s/caretaker’s own words/quoted.)
II. PRESENTING PROBLEM/RELEVANT HISTORY (Including client/member/caretaker/guardian reason for seeking services, precipitating factors,
symptoms, behavioral and functioning impacts, onset/course of issues, current behavioral health providers, services sought and expectations.) CURRENT BEHAVIORAL HEALTH PROVIDER NAME: PHONE NUMBER:
III. PAST PSYCHIATRIC/PLACEMENT HISTORY (First onset of illness, past diagnostic and treatment history, medications, hospitalizations):
Prior Outpatient Mental Health Treatment: □ No; □ Yes; Detail:
Psychiatric Hospitalizations: □ No; □ Yes;
Detail:
Prior Residential/Out of Home Placement: □ No; □ Yes; Detail:
Additional History/Comments:
IV. SUBSTANCE USE HISTORY (Past use of primary, secondary & tertiary current substance, incl. type, freq, method & age of 1st use.)
Check any/all that apply in past 12 months:
□ Alcohol Use; □ Illegal Drug Use; □ Injected Drug Use ; □ Tobacco Product Use; □ Prescription Drug Misuse; □ Non-Prescription Drug (OTC) Misuse
□ Alcohol and/or Drug Overdose; □ Alcohol and/or Drug Withdrawal; □ Problems caused by gambling; □ Trouble stopping any substance
□ Other/Describe:
Substance Use Treatment History: □ None; □ Outpatient; □ Intensive Outpatient; □ Residential/Inpatient; □ Detox;
□ Other/Describe: Hx of Drugs Used/Describe;
SUBSTANCE TYPE Include all use in last 30 days.
AGE OF
1ST USE YEARS IN
LIFETIME
DAYS IN
PAST 30 DAYS SINCE
LAST USE AMOUNT ROUTE OF ADMINISTRATION
□ Oral; □ Nasal; □ Smoking; □ Non-IV Injxn; □ IV
□ Oral; □ Nasal; □ Smoking; □ Non-IV Injxn; □ IV
□ Oral; □ Nasal; □ Smoking; □ Non-IV Injxn; □ IV
PHYSICAL
V. CURRENT MEDICAL CONDITIONS (Check all that apply)
□ Pregnant Due date: Prenatal care:
□ None Reported □ Congestive Heart Failure □ Asthma □ Seizure □ Cancer □ Underweight
□ High Blood Pressure □ Stroke □ Emphysema □ Cirrhosis □ Chronic Pain □ Overweight
□ Heart Disease □ Diabetes □ Epilepsy □ Digestive Problems □ Thyroid Disease □ Sexually Transmitted Dz.
□ Other/Describe:
VI. CURRENT & PAST MEDICATIONS(Including non-psychotropic medications)
Medication Name Dose Freq. Route Current COMMENTS (Reason Prescribed/Response, etc.)
24
□ Yes; □ No
□ Yes; □ No
□ Yes; □ No
□ Yes; □ No
VII. ALLERGIES □ No Reported Drug or Food Allergies; □ Other/Describe:
VIII. PRIMARY CARE PHYSICIAN NAME PHONE FAX
IX. ADDITIONAL SIGNIFICANT MEDICAL HISTORY (Diagnosis, Hospitalizations, Surgery, labs values, status of conditions, etc.)
SOCIAL
X. LEGAL STATUS
Current Legal Status: □ None; □ ProbaUon; □ Charges Pending; □ DCFS;
□ OJJ; □ Other
Past Legal Status: □ None; □ DCFS; □ OJJ; □ Other
Comment/Detail:
Comment/Detail:
XI. FAMILY HISTORY (relationship status with relatives, family involvement in treatment, and living status of significant relatives):
Custodial Status: □ Independent Adult; □ Biologic Father; □ Biologic Mother; □ Joint Biologic Parents; □ Gov’t/Judicial; □ Other:
Adverse Circumstances in Family of Origin: □ N/A; □ Poverty; □ Criminal Behavioral; □ Mental Illness; □ Substance Use; □ Abuse; □ Neglect;
□ DomesUc Violence; □ Violence; □ Trauma; □ Other/Describe:
Summarize family history and child-rearing practices:
XII. TRAUMA HISTORY
History of Trauma: □ None; □ Experienced; □ Witnessed; □ Abuse; □ Neglect; □ Violence; □ Sexual Assault;
□ Other/Describe:
Summarize trauma history:
XIII. LIVING SITUATION (Current status and functioning)
a. Primary Residence: □ Parent/Guardian Home; □ RelaUve’s Home; □ Out of Home placement; □ Homeless; □ Other/Describe:
How long at current residence?
Family/Household Composition:
b. Summarize current living situation:
XIV. EDUCATIONAL/EMPLOYMENT STATUS a. Current Educational Placement/Employer:
Current or Highest Grade Completed/Degree:
Difficulties with Reading/Writing: □ No; □ Yes; Estimated Literacy Level:
b. Summarize educational history and status: .
XV. SOCIAL HISTORY AND COMMUNITY INTEGRATION
a. Current status and functioning (Involvement in the community, social supports and activities, social barriers)
Does Client/Member feel supported by friends or family? □ Yes; □ No;
Recreational Activities:
Self-Help Activities:
b. Summarize social and community involvement:
CURRENT STATUS
25
XVI. MENTAL STATUS EXAMINATION (Circle or Check all that apply.)
a. GENERAL APPEARANCE □ Healthy; □As stated Age; □ Older Than Stated Age; □ Young-looking; □ TaVoos; □ Disheveled; □ Unkempt;
□ Malodorous; □ Thin; □ Overweight; □Obese; □ Other/Describe:
b. BEHAVIOR & PSYCHOMOTOR ACTIVITY □ Normal; □ OveracUve; □ HypoacUve; □ Catatonia; □ Tremor; □ Tics; □ CombaUve;
□ Other/Describe:
c. ATTITUDE □ Optimal; □ Constructive; □ Motivated; □ Obstructive; □ Adversarial; □ Inaccessible; □ Cooperative; □ Seductive; □ Defensive;
□ Hostile; □ Guarded; □ Apathetic; □ Evasive; □ Other/Explain:
d. SPEECH □ Normal; □ Spontaneous; □ Slow; □ Impoverished; □ Hesitant; □ Monotonous; □ Soft/Whispered; □ Mumbled; □ Rapid;
□ Pressured; □ Verbose; □ Loud; □ Slurred; □ Impediment; □ Other/Describe:
e. MOOD: □ Dysphoric; □ Euthymic; □ Expansive; □ Irritable; □ Labile; □ Elevated; □ Euphoric; □ EcstaUc; □ Depressed; □ Grief/mourning;
□ Alexithymic; □ Elated; □ Hypomanic; □ Manic; □ Anxious; □ Tense; □ Other/Describe:
c. AFFECT □ Appropriate; □ Inappropriate; □ Blunted; □ Restricted; □ Flat; □ Labile; □ Tearful; □ Intense; □ Other/Describe:
g. PERCEPTUAL DISTURBANCES □ None; Hallucinations: □ Auditory; □ Visual; □ Olfactory; □ TacUle;
□ Other/Describe:
h. THOUGHT PROCESS □ Logical/Coherent; □ Incomprehensible; □ Incoherent; □ Flight of Ideas; □ Loose AssociaUons; □ TangenUal;
□ CircumstanUal; □ Rambling; □ Evasive; □ Racing Thoughts; □ PerseveraUon; □ Thought Blocking; □ Concrete;
□ Other/Describe:
i. THOUGHT CONTENT □ PreoccupaUons; □ Obsessions; □ Compulsions; □ Phobias; □ Delusions; □ Thought BroadcasUng;
□ Thought InserUon; □ Thought Withdrawal; □ Ideas of Reference; □ Ideas of Influence; □ Delusions;
□ Other/Describe:
j. SUICIDAL/HOMICIDAL IDEATION □ Suicidal Thoughts; □ Suicidal AVempts; □ Suicidal Intent; □ Suicidal Plans; □ History of Self-Injurious Behavior
□ Homicidal Thoughts; □ Homicidal AVempts; □ Homicidal Intent; □ Homicidal Plans;
□ Other/Describe:
k. SENSORIUM/COGNITION □ Alert; □ Lethargic; □ Somnolent; □ Stuporous; Oriented to: □ Person; □ Place; □ Time; □ SituaUon;
□ Normal ConcentraUon; □ Impaired ConcentraUon; □ Other/Describe:
l. MEMORY Remote Memory: □ Normal; □ Impaired; Recent Memory: □ Normal; □ Impaired; Immediate Recall: □ Normal; □ Impaired
□ Other/Describe:
m. INTELLECTUAL FUNCTIONING (Estimate) □ Above Avg.; □ Normal/Avg.; □ Borderline; Mental Retardation: □ Mild; □ Moderate; □ Severe
□ Other/Describe:
n. JUDGMENT □ CriUcal Judgment Intact; □ Impaired Judgment; □ Other/Describe:
o. INSIGHT □ True EmoUonal Insight; □ Intellectual Insight; □ Some Awareness of Illness/symptoms; □ Impaired Insight; □ Denial;
□ Other/Describe:
p. IMPULSE CONTROL □ Able to Resist Impulses; □ Recent Impulsive Behavior; □ Impaired Impulse Control; □ Compulsions;
□ Other/Describe:
XVII. RISK ASSESSMENT: Assess potential risk of harm to self or others, including patterns of risk behavior and/or risk due to personality factors, substance use,
criminogenic factors, exposure to elements, exploitation, abuse, neglect, suicidal or homicidal history, self-injury, psychosis, impulsiveness, etc.
a. a. Risk of Harm to Self: □ Prior Suicide AVempt; □ Stated Plan/Intent; □ Access to means (weapons, pills, etc.); □ Recent Loss; □
Presence of Behavioral Cues (isolation, giving away possessions, rapid mood swings, etc.); □ Family History of Suicide; □ Terminal Illness; □
Substance Abuse; □ Marked lack of support; □ Psychosis; □ Suicide of friend/acquaintance; □ Other/Describe:
b. b. Risk of Harm to Others: □ Prior acts of violence; □ DestrucUon of property; □ Arrests for violence; □ Access to means (weapons); □
Substance use; □ Physically abused as child; □ Was physically abusive as a child; □ Harms animals; □ Fire seXng; □ Angry mood/agitation;
□ Prior hospitalizaUons for danger to others; □ Psychosis/command hallucinaUons;
□ Other/Describe:
c. Client/Member Safety & Other Risk Factors: □ Feels unsafe in current living environment; □ Feels currently being
harmed/hurt/abused/threatened by someone; □ Engages in dangerous sexual behavior; □ Past involvement with Child or Adult Protective
Services; □ Relapse/decompensaUon triggers;
□ Other/Describe:
d. □ Inappropriate sexual behaviors □ Sex offender status □ Pending sex offense charge □ Report or Investigation □ Other: _
e. Additional Risk Factors
f. Describe recipient’s preferences and desires for addressing risk factors, including any Mental Health Advance Directives or plan of response to
periods of decompensation/relapse (Ex. Resources recipient feels comfortable reaching out to for assistance in a crisis.):
26
XVIII. CULTURAL AND LANGUAGE PREFERENCES (Language, Customs/Values/Preferences)
a. Spiritual Beliefs/Preferences:
b. Cultural Beliefs/Preferences:
XIX. PRINCIPAL DIAGNOSES
AXIS I
AXIS II
AXIS III
AXIS IV
AXIS V Current: Highest Past Year:
XX. INTERPRETIVE SUMMARY: Briefly describe client/member’s global preferences/hopes for recovery, your clinical summary, and recommended
treatments/assessments, level of care, duration.
a. Recommended Services: (Check all that apply.) □ Family Therapy; □ Individual Therapy; □ Group Therapy; □ Alcohol/Drug Assessment; □
Alcohol/ Drug Individual Therapy; □ PSR; □ CPST; □ Other/Describe:
b. Other Services/Linkages Needed: □ Vocational Services; □ Social Services; □ EducaUonal Services; □ Medical Services/PCP; □ Self help Groups;
□ Other/Describe:
c. Additional Comments:
SIGNATURE
PRINTED NAME OF ASSESSOR SIGNATURE LMHP STATUS DATE
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Appendix 8
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Appendix 9
Description of Required Courses for WAAs and FSO
Core Training Course Descriptions for Wraparound Facilitators, Youth and Parent Support
Specialists
Introduction to Wraparound (3-day)
This is the first training of the series for frontline wraparound practitioners and parent and youth
support specialists, supervisors, and directors as well as community partners who may participate in a
child and family team process. Through attendance at this training, participants will be able to:
• Gain an understanding of the critical components of the wraparound process in order to provide
high fidelity wraparound practice; and
• Practice the steps of the process to include eliciting the family story from multiple perspectives,
reframing the family story from a strengths perspective, identifying functional strengths,
developing vision statements, team missions, identifying needs, establishing outcomes,
brainstorming strategies, and creating a plan of care and crisis plan that represents the work of
the team and learn basic facilitation skills for running a Child and Family Team (CFT) meeting.
Engagement in the Wraparound Process (1-day)
This is the second training in the series for frontline wraparound practitioners and parent and youth
support specialists, supervisors, and directors as well as community partners who may participate in a
child and family team process. Through attendance at this training, participants will be able to:
• Identify barriers to engagement:
• Develop skills around engaging team members and the family; and,
• Utilize research-based strategies of engagement for increased positive outcomes for youth and
their families
Additional Course Descriptions for Wraparound Facilitators
Intermediate Training – This is an advanced level training to ensure the quality of the statewide
implementation of wraparound as well as fidelity to this process. The national trainer will be work
with each region to identify underlying areas of needs and strategies to address the needs to ensure
the quality of services for the family. This training is individualized based on the needs of the region.
Day 1 – All participants identify areas in which they are struggling experiencing challenges as an
agency as well as their strengths in order to move toward quality practices.
Day 2 –All participants will engage in active learning strategies including practicing skills in their areas
of identified needs.
Participants- Required for all direct care staff in the WAAs
Prerequisite for Intermediate Training – Must have completed 3 day Introduction and have a
minimum of 6 months experience in implementation, including coaching.
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Additional Course Descriptions for WAA Supervisors/ Coaches
Introduction to Training and Coaching Tools (1-day for WAA supervisors/coaches only)
This training is provided for local supervisors/coaches in the WAA. Through attendance at this
training, participants will be able to:
• Identify the tools necessary to support quality wraparound implementation;
• Develop an increased understanding of the role of the local coach; and
• Learn how and when to utilize coaching tools to support quality wraparound peer parent support
partners.
Additional Course Descriptions for FSO Parent and Youth Support Specialists
Core Skills for FSO Parent and Youth Support Specialists
This is the third training in the series for frontline wraparound parent/youth support specialists,
supervisors, and directors to enhance their skills and move toward higher quality practice. Common
implementation challenges are addressed in this training; however, topics can be adjusted based on
individual, organizational, or state need. Through attendance at this training, participants will be able
to:
• Introduce self as a parent of a child with emotional or behavioral challenges and explain the role
of the Youth and Parent Support Specialist;
• Effectively share own story in a way which builds connection, confidence, and hope for the family
relevant to the family's culture, beliefs and situation; • Effectively use PSS/YSS lived experience as a learning tool for professionals;
• Prepare the parent to share their perspective in a way that the team can understand;
• Partner with care coordinator in implementing a plan and activities individualized for the family
Additional Course Descriptions for Parent and Youth Support Supervisors
Advanced Skills for FSO Youth and Parent Support Specialists (for supervisors only)
This training is provided for wraparound youth and parent support specialist supervisors/
managers. Through attendance at this training, participants will be able to:
• Identify the essential elements of quality youth and parent support implementation;
• Develop an increased understanding of the role of the supervisor in quality youth and parent
support wraparound implementation;
• Learn how to manage quality throughout the phases of wraparound implementation;
• Learn how to utilize supportive tools to develop quality wraparound parent support partners; and
• Learn how to transfer knowledge and skills to the workforce.