This is the Services guide.
Tap on a topic and then subtopic below to navigate this guide.
For purposes of this guide, Integrated Care Management describes how Adult Mental Health - Targeted Case Management and Behavioral Health Home Services each serve to support an Integrated Care approach. It replaces the separate guides for each service as the services differ only in how they are funded, and some of the required elements required for eligibility and initiaton of these services.
Before reading this guide, read or review the following:
If you have questions or comments on this guide, please send them using the Feedback Link below.
This guide was most recently updated on May 19, 2022.
The goals of Integrated Care Management are to:
Service | Count of Financial Responsibility | Payers | Eligibility and Diagnoses | Conflicting Services or Special Instructions |
---|---|---|---|---|
Behavioral Health Home Services | Any county in Minnesota | Medical Assistance or any MA Managed Care program.
Never Minnesota Care with any payer. |
Adults with serious mental illness or children with mental illness or behavioral disorders based on a confirmed (with an internal or external DA, on file and reivewed) diagnosis within the last 6 months. | Recipients who receive
-Mental health targeted case management (MH-TCM) -Assertive Community Treatment (ACT) or Youth Assertive Community Treatment (YouthACT) -Relocation Service Coordination Targeted Case Management(RSC-TCM) -Vulnerable adult/developmental disability targeted case management(VA/DD-TCM) -Health care homes care coordination are not eligible to receive Behavioral Health Home Services. |
Adult Mental Health - Targeted Case Management | Lake
St. Louis |
Medical Assistance or any MHCP Managed Care program (PMAP), including UCare | Adults with Severe, Persistent Mental Illness (SPMI) and a Medical Necessity Statment, recorded in an eligibliity screening.
The eligibillty screening is required every three years and is valid for three years. |
Individuals cannot receive both AMH-TCM and BHH Services
Check with your supervisor if you become aware of individuals receiving other services and you are not sure if they conflict |
Adult Mental Health - Targeted Case Management | Hennepin | -BCBS of Minnesota -Health Partners -Hennepin Health -Medica Any payer during a 60-day transition period having moved from another county where we have been providing TCM services LONG-TERM OR NEW REFERRALS: never Medical Assistance or UCare Other MCOs possibly with prior authorization. |
Adults with Severe, Persistent Mental Illness (SPMI) & Medical Necessity Statment (Eligibility Screening) | If the payer is Hennepin Health
Complete the Mental Health Targeted Case Management Notification Form Individuals cannot receive both AMH-TCM and BHH Services Check with your supervisor if you become aware of individuals receiving other services and you are not sure if they conflict |
Adult Mental Health - Targeted Case Management | All Other Counties | Any payer during a 60-day transition period having moved from another county where we have been providing TCM services LONG-TERM Never Medical Assistance or UCare Other MCOs with prior internal authorization. |
Adults with Severe, Persistent Mental Illness (SPMI) & Medical Necessity Statment (Eligibility Screening) | Individuals cannot receive both AMH-TCM and BHH Services
Check with your supervisor if you become aware of individuals receiving other services and you are not sure if they conflict |
Adult Mental Health - Targeted Case Management Services require Eligibility Screening, as follows:
And eligibility screening for Case Management is required only every three years and is valid for three years.
Persons with SPMI (Serious and Persistent Mental Illness) are eligible for case management. A "person with serious and persistent mental illness" means an adult who has a mental illness and meets at least one of the following criteria:
Use the following flowchart to determine eligibility for Case Management services:
Do not provide Case Management to residents of counties other than Lake and St. Louis who have UCARE Insurance. UCARE'S policies and procedures require that Case Management providers have a local county contract with the county where the recipient resides. Provide them with a list of contracted providers in that county, or offer BHH services as an alternative.
Ask your Program Manager for permission to initiate AMH-TCM services for residents of other than Lake and St. Louis Counties.
We do not provide AMH-TCM services to residents of Carlton County without prior notification to Carlton County.
Referrals for Case Management for residents of Lake County must come from the county. If a Diagnostic Assessment indicates a need for Case Management for a Lake County resident, and the individual wants Case Management:
> With a signed release, send the DA and referral for Case Management to Lake County Health and Human Services.
> They will complete the eligibility screening and refer the individual to us, if they determine it is appropriate.
Lake County referrals should come from Lake County only. Direct 3rd parties to Lake County, instructing them to send the request and Diagnostic Assessment to Lake County for eligibility screening and a referral.
If our Diagnostic Assessment recommends new Case Management services for a Lake County resident, we should do the same.
When we receive a referral and complete an eligibility screening for a resident of St. Louis County, who also has straight Medical Assistance (non-PMAP/non-MCO) insurance, please complete the following document and send it to St. Louis County:
It is not necessary to complete this form for a client who begins services on a PMAP and then loses coverage temporarily. Only for those clients who first initiate services in St. Louis County on straight Medical Assistance.
Instructions for Using This Form
It is strongly recommended that you fill out this form entirely on your laptop to the point where it is ready for signatures. (It's just easier.) Then email it to yourself and use the signing part of the instructions for using it on the iPad below to have your client sign it. But you You can fill out the entire form, and get signatures on an iPad or phone as follows:
When a current client moves to a new county where we can no longer provide Case Management Services, you may continue to provide these services for up to 60 days, or until you have connected them with a provider in their new county-of-residence, whichever comes first. If we have a presence in the new county-of-residence, referral and transfer to BHH services is also an option.
Explain this, and then explain options. Give the individual a list of Case Management providers in their county of residence and offer to make a referral, or offer BHH services as an alternative if the individual does not want to change providers.
Process Step | Adult Mental Health - Targeted Case Management Services | Behavioral Health Home Services | Deadline |
---|---|---|---|
Notification and Authorization Forms | A signed Treatment Consent form
An Notification of Adult Service Initiation and associated documents as required by that form, depending on the county and payer |
Notification of Eligibility for BHH Services (DHS-4797) The Service Coordinator sends the completed Notification of Eligibility form to the MCO contact for all persons with PMAP health coverage. BHH Services, Rights, Responsibilities, and Consent form (DHS-4797B) |
Prior to the first service following the Intake Interview, the provider must document how they reviewed the DHS-4797B with the member and also document the member’s consent to receive BHH services. The member’s consent may be documented either by keeping a DHS-4797B signed by the member in the provider’s records or by documenting how the provider reviewed the DHS-4797B with the member and then documenting the member’s preference for verbal consent. |
Eligibility Screening | The adult referredl has:
A diagnosis of SPMI Depending on the rationale for eligibility, a statement of medical necessity from the Clinician who completes the DA or reviews a DA provided by others Can recieve Case Management services from us based on County of Residence and Payer, above Elects to receive Case Management Services from Accend after having been explained options Complete the AMH-TCM Eligibility Screening in the Intake Integrated Functional and Health & Weillness Assessment and see Special Instructions for County-Specific Referrals above. |
The referred adult or child has: A diagnosis of Serious Mental Illness or Emtional and Behavioral Disorder A recommendation for BHH services in the Diagnostic Assessment Elects (or parent/guardian elects) to receive BHH from Accend after having been explained all options *Prior to conducting and eligibility screening for BHH services, you must obtain authorization for intitiating services above. |
Prior to the first service following the Intake Interview.
Eligibility screening for BHH is not required to be updated. Eiigibiilty screening for AMH-TCM must be updated every three years. |
Authorization for Release of Information | Complete ROI using TabsTM RO forms for all applicable health care providers and send to providers to request medical records as needed
or follow instructions for reviewing medical records in Epic systems found in our Medical Records guide |
Obtain signatures on the Authorization for Release of Protected Health Information (DHS-4797C)* and send to providers to request medical records as needed or follow instructions for reviewing medical records in Epic systems found in our Medical Records guide |
At intake or during the intial assessment and information-gathering process |
Required Assessments and Deadlines | A Diagnostic Assessment with one year prior to admission and updated every three years. An Integrated Funtional, Basic Needs and Health and Wellness Assessment including all elements applicable to Case Management, and updated every 180 days. A Client Status Assessment is required within 30 days of admission and every 180 days thereafter. |
A Diagnostic Assessment with one year prior to admission. No annual update required unless the recipient is recieving other mental health services where it is required. For adults, an Integrated Funtional, Basic Needs & Health and Wellness Assessment For children an Basic Needs Assessment and Health and Wellness Assessment |
DA - prior to admission and updated annually if the individual receives an services other than BHH
For Adults the Adult Intake Functional Assessment within 30 days of intake, updated within 90 days and every 365 days thereafter, or if the individual exhibits a significant change in functioning or life-changing event. For children, the Basic Needs Assessment within 30 days of admission, and The Child Health and Wellness Assessment with 90 days of admission, then updated every 365 days. |
Service Plans | An Integrated Care Plan for Case Management and all other mental health services | An Integrated Care Plan for BHH and all other mental health services | Within 30 days of admission
updated within 90 days and every 6 months thereafter |
Assessment, Planning, Progress Review, Monitoring Quality and Coordinating services are the key core elements of Integrated Care Management. This is not paperwork or a compliance exercise. It is the core responsiblity and activity of high quality Integrated Care Management. By doing this important work, Integrated Care Managers make possible, enhance, and assure coordination of all of the other services we provide and integrate these services with other health care, mental health, residential, vocational support, and social services.
TabsTM offers several key tools to accomplish this work. These include:
While not specifically described in the diagram here, as one of the four core services, helping the individual's you serve with maintaining health care coverage is essential, because without it, they cannot receive the medically necessary services to which you will refer them. A large number of the people to whom we provide Integrated CareManagement services see their insurance lapse for many reasons, but most often because they do not complete eligibility renewal applications and required verifications on time when their annual renewal is due. Read more about the steps you should take to monitor and help individuals with eligibility renewal under the topic Insurance Advocacy in the Advocacy section of this guide.
Our referrals most often come to us because they have immediate unmet basic needs. These might be financial, housing, food, safety, health care, or other unmet needs. While assessment and service planning is an important first process in developing and delivering Integrated CareManagement services, it should be done in the context of meeting immediate needs. Helping your client to identify resources and get these needs met is an ideal opportunity to learn about what has led to their current status, as well as what strengths and resources they have that will help them better meet needs and avoid these crises in the future.
Conduct initial assessment and planning for Integrated Care Management services while responding to the immediate needs of persons referred
Meet deadlines for initial and ongoing assessment and planning for Integrated Care Management services
Write a measurable Integrated Care Plan that prioritizes client goals and objectives and identifies strenghts and resources, needs and barriers, and supports and services needed to achive goals and objectives.
Deliver services that are characterized by the four core elements of Integrated Care services: assessment, planning, referral and linkage, monitoring and coordination.
Refer individuals to services and supports they need.
Monitor quality and engagement of the services an individual receives.
Monitor internal service quality, engagement for internal and other services using reports and tools in TabsTM.
For clients who are new to Accend, use the Adult Intake FA/HWA. This will expire in 90 days by which time you should complete a full FA/HWA.
The core document for updating this assessment for ongoing services the Integrated Care FA and HWA Update This process examines each individual's strengths and resources, deficits and barriers to independence, optimal physical and mental health, and quality of life. The integrated Functional and Health and Wellness Assessment identifies what services and supports the individual needs across all domains where deficits exists and should make specific recommendations for services in each of these domains.
The Integrated Care FA and HWA Update is a document that combines several other required assessments for Case Management, BHH and other services. These include:
A Client Status Assessment is required within 30 days of admission and every 180 days thereafter.
For children, we use the Basic Needs and Child Health & Wellness Assessment and Crisis Response Plan.
Assessment is the first priority in Integrated Care Management, but high quality assessment is much more than completing the document. It is a dynamic process used to identify current strengths and resources, needs, and deficits, and to prioritize these into Integrated Care Plans, Action Lists, and Referrals. It is not a process that occurs just once every 6 months, either. It is ongoing. The time to begin on the update to any assessment is the day after you have completed the previous one.
While conducting assessment, complete all of the following associated tasks:
The Health Care and Other Referrals and Action Lists are tools meant to be used, not as a compliance exercise, but as a to-do list to ensure that a recipient's healthcare and mental health needs are being met. For each client, develop a specific Action List and Referrals List based on their specific needs should inform priorities.
Our payers have also asked us to develop processes to assure quality care in a variety of specific ways. What follows are examples of items that UCare has asked included in Action Lists. While not a comprehensive list, it highlights some key areas on which we should focus for all clients.
The Integrated Care Plan brings together all services individuals receive from Accend into one integrated plan. (And exception to this is children who received EIDBI services - EIDBI plans, being more complex, are kept separate.)
It is the Integrated Care Manager's primary duty to complete or facilitate completion of all necessary assessments, and facilitate the development of an Integrated Plan.
Complete the Integrated Care Plan following these steps and guidelines:
For more information about writing person-centered Long-Term Goals and measurable Integrated Care Plan Objectives, see the section on Assessment and Planning in this guide.
Referral and linkage involves interactions with the recipient to:
Referring an individual to services does not stop with the phone call, fax, or referral form. Integrated Managers identify, with high quality assessment, what barriers might exist for an individual to participate in recommended services. Can they get to the service? Do they have transportation? Do symptoms, such as depression, anxiety, or phobias prevent them from participating? Do they have children who may need childcare while they participate in services? These are just a few considerations that the thoughtful Integrate Care Manager must take into account when making referrals, and address with a comprehensive Integrated Care Plan that removes these and other barriers to participation.
Once you have identified needs, made referrals, and an individual is participating in services, monitoring and coordination of the services is the primary role of the Integrated Care Manager and serves these purposes:
At regular intervals associated with treatment/service planning updates, Integrated Care Manager Managers should offer to each person served an opportunity for a Recovery Team Meeting. The purpose of the Recovery Team Meeting is to bring together all providers and other key natural support persons chosen by the individual to review progress, set new goals, and further define each person's health and recovery vision.
The Integrated Care Manager assigned to each person served should offer and facilitate this process if that individual chooses.
At Accend, we organize ourselves using the strategy of Integrated Teams. This means that, as much as possible, when our clients receive more that one service from us we refer our clients to providers on the same team where they receive Integrated Care Management tservices. This is not always possible. At times, there are providers, psychotherapists for example, who are members of a different team, but who have particular specialties that are a better fit for the individual's needs.
Regardless of whom the individual's providers are for other services they receive at Accend, Integrated CareManagers are tasked with coordinating these services, assuring that where, for example, a recipient of Integrated Care Management also receives ARMHS, the ARMHS plan is coordinated with and supports the goals and objectives in the Integrated Care Plan.
When a recipient of Integrated Care Management also receives Psychotherapy services, the Integrated Care Manager works hand in hand with the therapist to ensure that Psychotherapy services are responsive to needs, and that Integrated Care Management (and other services, such as ARMHS or CTSS) support the goals and objectives of Psychotherapy.
Finally, for all services, the Integrated Care Manager assures that individuals other basic needs are met so that mental health treatment can be as effective as possible.
When recipients' receive other services at Accend, follow these steps to assure engagement, quality and effectiveness of these services:
For recipients receiving other services, coordinate communication with the full team to review progress and engagement in services:
When functioning is a barrier to goals, the Integrated Care Plan spells out the longer-term, or ultimate, goals and outcomes, and connects the recipient to supports to remove functional barriers. For recipients who receive other services, the Integrated Care Manager must ensure that the Plan is coordinated, and demonstrates clearly how each service will support the goals and objectives in it.
When recipients disengage from Integrated Care Management services but remain connected to other services, coordinate with those providers to explore the reasons why the recipient has disengaged.
Having phone or face-to-face contact with all Integrated Care Management Services recipients in the first 10 business days of each month provides an opportunity to triage needs, plan, and prioritize for the remainder of the month. To do this:
When you are unable to reach an individual for a protracted period of time, make these additional efforts:
Frequency of contact is person-centered, but expectations for minimum contact with individuals receiving Integrated Care management services are as follows:
Minimum contact for Integrated Care services are as follows:
These are minimum standards. Best practices are a telephone or face-to-face contact in the first ten business days every month to review progress and assess needs, and follow-ups as needed throughout the month, with face-to-face contact every month begin the preferred standard.
Tap here for a tutorial (ICM My Efforts Report) on how to use and Advanced search to track your contacts and contact efforts with Case Management and Behavioral Health Home Services clients.
In Case Management, if you have had only telephone contact with an individual by phone during the previous two months,you must have face-to-face contact that month for the service to be billable. BHH phone contacts are acceptable for 5 months before a face-to-face contact is necessary.
*During the COVID-19 state-of-emergency, phone contacts are allowed in place of face-to-face services as telemedicine.
Working with recipients to assure that they receive routine well-care and treatment for physical health conditions is a priority in Integrated CareManagement services. Providing support as needed to each individual to maintain health care coverage is the first step in this process.
Regardless of whether or not each recipient has significant health problem, monitor and record health care in TabTMas follows.
As needed, develop person-centered goals and objectives for improving each individual's health and access to and management health care services in the Integrated Plan. Seek advice from the Accend RN, and each person's physician for goals and objectives involving such things as special diets, exercise, herbals or supplements, especially for individuals who have serious health conditions such as low or high weight, diabetes, high blood pressure, etc.
A key component of your job as a Behavioral Health Home provider is to educate the people you support about recommended well care, including annual exams, immunizations, and other recommended health care screenings for persons of various ages, backgrounds, and health histories.
Your first task is to connect each person with an ongoing relationship a primary care physician. That physician will make recommendations based on the individual's exams and health histories.
At the same time, you should remain aware of standard recommendations for immunizations and health screenings. Tap on the following links for information about these.
A core strategy of Behavioral Health Home Services is to systematically use a registry to identify specific population subgroups requiring specific levels or types of care. We have developed the following utilities in TabsTM to support this process.
The Diagnosis Table in TabsTM allows for entry of diagnoses received from medical and mental health professionals. To use this tool, select the individual from the search and navigate to diagnoses as shown in the image to the left. From there you may view or add diagnoses to the table.
To use the diagnosis utility:
Use Health Action Lists to track health care, social services, housing, vocational and a variety of other needs. For each person served with BHH services, enter well care needs as standard.
Track medications in the Medications table as follows:
The appointments utility offers you the ability to enter scheduled appointments and then return to enter results. After navigating to this utility, you may tap to edit a current appointment or Add a new one. Fill out the form completely and enter medications changes and lab tests in those utilities as needed.
The labs tracking utility is simple to use. Tap on a lab test from the dropdown menu and add it. The labs utility provides a history for each lab test over time, as follows:
The immunizations tracking utility works the same. Tap on an immunization from the dropdown menu and add it.
Finally external documents of all kinds can be stored in each person's file. Navigate to documents as shown to the left. Once there, you may view a list of current documents in the file, or add a scanned document. Medical records typically will do this for you, however, if you submit any external or paper document.
To search the registry, navigate to Admin Tools, then Audits and Reports. Tap here for a visual guide for using the Registry Search.
Results of the search will appear in a table, which can be reviewed online, or downloaded as a text-delimited file (spreadsheet) for further sorting and analysis.
TabsTM contains information about immunizations, cancer screenings and disease-specific lab results for the people in your practice. You can search it to identify those persons overdue for annual or other well-care exams, screenings and immunizations and any other well-care services they might need.
You will do this by using the following resources, and the recommendations of each person's physician to create problem lists. These lists, customized to each individual, should identify the well-care, screenings and immunizations they need at this time.
Queries of problem lists can also identify individuals who have specific problems in managing preventative and chronic health care issues. TabsTM queries will help track if each person is meeting these preventive and chronic care measures.
While assisting the people you serve with health care visits, you will prepare in advance and ask physicians and staff to screen the people you support for diseases and for recommended services based on their age, sex, diagnosis, etc. You will remind physicians and providers to provide preventive care services (e.g., immunizations), and help physicians and providers to better manage chronic conditions.
Your Integration Specialist will provide guidance on clinical practice best practices and guidelines for preventive and chronic care services. You will use these to establish target levels for selected health indicators. Most practices use evidence‑based national guidelines. Your Integration Specialist, working in consultation with physicians and specialists will define which targets to set for each indicator.
A gap in care exists when someone is overdue for a service that should be done periodically (known as a process care gap) or when a someone is not meeting the goal range for a particular disease or condition, such as having an blood level marker in a routine test higher or lower than the recommended target. Care gaps of selected indicators are identified from the gaps queries that your Integration Specialist will develop.
During preparation for health care appointments or during progress reviews with each person you serve, you will identify care gaps, discuss them with the person and update that individual's problem list to identify the unmet need and make plans to follow up.
The Integration Specialist can use the Patient Registry to identify patterns and trends in specific areas of need. Some examples are:
Document Integrated Care Management services objectively and specifically in progress notes.
Use appropriate service types when documenting Integrated Care Management services.
Integrated Care management documentation must describe Integrated Care management activities but objectives, specific and free of lingo. Specific and free of lingo means: describe specifically what you did, avoiding terms like "assessed," "referred," "linked," or "monitored" in favor of describing what you did, e.g. "read the custom time report and progress notes for ARMHS services," "scheduled an appointment with," "spoke with," etc.
For more information on writing high quality progress notes, see the section on documentation in this manual at Documentation and Electronic Health Records: Progress Notes.
Use the following table for guidelines on what service types to use when documenting contacts with individuals for Iintegrated Management services. Only these services trigger billing for Case Mangement or Behavioral Health Home Services in a given month and at least one contact service must be provided each month.
When documenting services, you will be asked to select a meeting type. This determines the billing code. Face-to-Face or Telehealth Services are required at least once every 90 days for each person servec.
Description of Activity | Service Category | Billable Service |
---|---|---|
Intervention and assistance provided previous to completion of the first Integrated or BHH Service Plan or other Interventions unrelated to current goals and objectives. | Behavioral Health Home
Case Management |
BHH Intervention CMGT Intervention |
Regular ongoing services with an active plan | Behavioral Health Home
Case Management |
Behavioral Health Home Services
Case Management |
Assessment and Planning done face to face or by phone with the recipient | Behavioral Health Home
Case Management |
BHH Assessment and Planning Interview
CMGT Assessment and Planning Interview |
For any contact service provided face-to-face or by telephone, use these add-ons to identify service coordination or referrals made in conjunction with (during or immediately following) the service. When the add-on service occurs directly following a contact, include the time in the contact note and describe the add-on service in the intervention narrative.
If you provide an add-on service to services, but provide that add-on service after traveling back to the office, record your travel back to the office as Travel During Service. Explain this in your narrative. This is only allowed when the service, travel, and add-on service provided at the office are consecutive/contiguous (not uninterrupted by other activities). If you do something else in between, do not use an add-on, rather document the coordination, referral, or advocacy as a separate service at the precise time that it occured.
Service Name | Use |
---|---|
Advocacy During or Following Service | When during or after a service you make advocacy calls, write emails, etc. Overlaps allowed only with the service with which it is associated. (Meaning, you could provide this service in the middle of a split session where you speak with the client direclty before and after this activity while providing telehealth or phone services. Example: You have a direct (face-to-face or telehealh contact with the client. You then make some calls on the client's behalf, then you call them back or resume the service.) |
Assessment & Planning Interview Write Up | Use for time spent immediately following an interview to finish writing up findings, eliminating the need for another note. |
Being Observed/Mentored During Service | When Trainee is being observed while Trainee is providing a direct service. |
Being Shadowed During Service | When Trainer is being observed, Trainer is providing the direct service. |
Bus Pass Delivered | Please remember this add-on whenever providing a bus pass to a client to avoid claims (as have been alleged in the past) that we are not delivering them to the clients for whom they are intended when they are delivered by mail to the office. |
CMGT Pre Service Prep Work | May be used to account for time preparing for a service (reading assessments, gathering information, etc.) |
Contact & Scheduling Related to CCN | Document efforts to contact a cllient who cancels or no-shows. |
Coordination Related to Service | When during or after a service you make calls, write emails, etc., to other service providers for purposes of coordination. Overlaps allowed only with the service with which it is associated. (Meaning, you could provide this service in the middle of a split session where you speak with the client direclty before and after this activity while providing telehealth or phone services. Example: You have a direct (face-to-face or telehealh contact with the client. You then make some calls on the client's behalf, then you call them back or resume the service.) |
COVID Vaccine Assistance Offered | Very important to document our efforts to assure that clients get the help they need. |
Dental Care Appt During Services | When attending an appointment with client. |
Incident Report Filed | Very important to document when incidents are reported. |
Insurance Advocacy During/After Service | When during or after a service you provide assistance maintining or restoring health insurance coverage. Overlaps allowed only with the service with which it is associated. (Meaning, you could provide this service in the middle of a split session where you speak with the client direclty before and after this activity while providing telehealth or phone services. Example: You have a direct (face-to-face or telehealh contact with the client. You then make some calls on the client's behalf, then you call them back or resume the service.) |
Primary Care Appt During Services | When attending an appointment with client. |
Progress Review in Session | Progress review should always be done with clients. Use this add-on to demonstrate that. |
Recovery Team Meeting | Client must be present. |
Referral During or Following Service | When during or after a service you make referrals to services at Accend or to other providers. Overlaps allowed only with the service with which it is associated. (Meaning, you could provide this service in the middle of a split session where you speak with the client direclty before and after this activity while providing telehealth or phone services. Example: You have a direct (face-to-face or telehealh contact with the client. You then make some calls on the client's behalf, then you call them back or resume the service.) |
Specialist Care Appt During Services | When attending an appointment with client. |
Travel | Use only for direct services provided at a location other than one of our offices. |
Use the following service types for activities that do not include contact with individuals. These activities other than the last, while vital to the services, do not trigger a billing record for the service for the month.
Note Type | Use For |
---|---|
Referral Intake Discharge | Conducting an intake interview prior to a DA or established eligibility for case management, or activities related to discharge, writing a letter to the individual who has disengaged and lost contact, clerking the client status or other information in the EHR, etc.) |
Eligibility Screening | All activities associated with conducting and eligibility screening, including obtaining ROIs, gathering information, and writing the screening document. |
Contact and Scheduling | Telephone or written efforts to contact referrals or individuals currently served. |
Case Management Assmt No Contact | Writing the Functional Assessment, ICSP (Integrated Sevice Plan) or Progress review while not with the individual served. Reviewing previous assessments or plans while preparing for an interview or update. |
Referral to Services | Any conversations with the individual served about recommended services, or formal referrals to service providers. This may overlap with other activities. When this occurs during a direct service, use the Add-On referral type described below. |
Service Coordination | Monitoring and coordinating health care, mental health, residential, vocational, or other services, or talking with providers. When this occurs during a direct service, use the Add-On referral type described below. |
Advocacy No Contact | Advocating on behalf of individuals served with law enforcement, landlords, county financial workers, and a variety of other community members who are not direct service providers. |
Insurance Advocacy | Advocating on behalf of individuals served specifically regarding health insurance coverage. |
Cancellation By Provider | Cancellation of a planned appointment by you for any reason. |
Client Initiated Cancellation | Cancellation of a planned appointment initiated by the individual |
File Note | Miscellaneous recording of necessary information about an individual not fitting another category. |
Case Manager Associates must receive 5 hours of mentoring per week from a qualified Case Manager (includes Mental Health Professional who qualifies as a Case Manager). Mentoring may (and should) occur during Case Management service provision (the service is allowed to overlap with others.
The mentor should document Case Mgt Mentoring Others, and indicate on the note who is being mentored. The Associate should document Case Mgt Being Mentored, and indicate on the note who is doing the mentoring. These note types take place during other Case Management Activities.
Service Type | Detail |
---|---|
Case Mgt Mentoring Being Mentored | A Case Management Associate performing work in the presence of, or consulting with, a Case Management Mentor. |
Case Mgt Mentoring Others | A qualified Case Management Mentor consulting with or observing a Case Management Associate. |
Conduct global progress review and quality assurance that examines the outcomes of all health care, mental health, residential and vocational or educational and other services a recipient of Integrated Care Management recieves.
Integrated Care Management progress review and quality assurance is not limited to simple twice-per-year updates of required assessments and the ICSP.
Rather, it is an ongoing process that should be characterized by review of all of the health care, mental health, residential and vocational or educational and other services a recipient of Integrated Care Management needs, and is receiving.
A well-crafted Integrated Care Plan has identified the individual's current strengths and resources, and needs for services. Good Integrated Care Management is seeing to it that the individual is referred to, engaged in and receiving high quality services. The Integrated Care Plan review is a review of all of those services. As follows:
Especially when an individual receives more than one service from Accend, but also in cases where he or she receives these services from other providers, Integrated Care Managers should schedule Recovery/Support team meetings to review progress toward recovery and treatment goals. The most appropriate times to hold such a meeting are
TabsTM provides a utility for recording all of the key contact persons for persons served. Integrated Care Managers should keep this contact list up-to-date with all external service providers, family members, and other natural and formal support persons in each individual's support network and whom we may need to contact on behalf of recipients. Find this utility in the Client Info section.
Provide active and responsive services during transitions and placements
Assure continuity of care during transitions
As Integrated Care Manager, you are the lead facilitator and coordinator of the individual's support and treatment network during periods of transition and placement. We expect you to take an active role in facilitating successful transitions and placements with the goal of assuring successful transitions, and the best possible treatment outcomes in placement, and successful discharge planning.
When you learn of person's desire to move to a new area, your job is to immediately begin assessing the individual's needs (for housing, supports, services, etc.) in the new location and helping the individual to begin locating these resources prior to the move. This assessment and planning should include:
Following the move, if the individual remains in Minnesota, we follow-up with and continue Integrated Care Management services in the new location until the individual has obtained services with the new provider.
If the individual receiving services moves to a location where we provide te same services, offer and make arrangements for a transfer to an Accend Case Manager in the new location if that is what the person wants.
If the individual is moving to an area where we cannont provide Case Management services based on the individual's insurance or because we do not have a presence in the new location, offer one of two options:
Travel to the new location to provide services is allowed. Communicate with your supervisor about the frequency of necessary travel. Help the individual locate and use resources for the move. Provide services by telephone where possible, traveling to the new location only as necessary.
If the individual is moving to another state, do research on options for mental health services available in that state, and help the individual connect with these services prior to the move.
Some moves are temporary. These include moves to residential treatment, foster care, board and lodge, and other types of placements because placements in these facilities do not establish residency in the new county. When a move is temporary, continue Integrated Care Management services in the new location, unless the individual requests, and the payer (the host county or Managed Care Organization) agrees to a transfer the case.
When an individual is hospitalized, the Integrated Care Manager's role includes:
Your role as a Integrated Care Manager when an individual enters residential treatment is to be the central coordinator of treatment and care in the facility, treatment and discharge planning. Do all of the following:
When a recipient of Integrated Care Management services is placed in a nursing home temporarily (with an anticipated placement of less than 180 days) continue Integrated Care Management services, with responsibilities matching those of hospitalization, above. When the individual is placed long-term, arrange for a transfer of services to the nursing facility staff and social workers.
Use required steps to discharge a recipient when the individual
has achieved goals and objectives and stability in status and functioning;
has moved or disengaged from services; or
is no longer eligible for other reasons.
Disharge from Integrated Care Management may occur in any of the following circumstances:
Administrative Discharge occurs when a recipient ends services for any of the reasons listed below. In these cases, discharge immediately or as indicated in the specific line items (no 6-month closing period as for disengagement).
When discharging based on a finding in a recent DA or Eligibility Screening that Case Management Services are no longer medically necessary:
Consider that the individual may still be eligible for and need Behavioral Health Home Services.
If so, offer BHH services and transfer the case if the individual accepts. If the current Case Manager is competent to provide BHH services, no change of primary is needed. Complete the CMGT discharge and get to work immediately on BHH assessments.
Clinical Discharge occurs when the recipient:
For planned discharges, complete a Discharge Progress Review.
Inform an individual about his or her appeal rights when found ineligible for Case Management or BHH services.
Handle a recipient complaint or grievance about Integrated Care Management services.
Assist a recipient in filing a grievance with Minnesota Medical Assistance or a Managed Care Organization.
Any referral to or current recipient of Case Management services who is found ineligible for Case Management services as a result of a Diagnostic Assessment or screening may appeal this decision.
Any recipient of Case Management services may file a complaint or grievance about his or her Case Management, other mental health or health care services, or about actions or decisions taken by his or her payer (Medical Assistance or a Managed Care Organization) at any time.
Integrated Care Managers should assist any client who wishes to file a complaint or grievance. He or she may do so with an internal grievance that will be reviewed by an administrator at Accend, or she or she may file a compliant or grievance with her or her payer, using the resources below.
Supervision of Integrated Care Management Services must adhere to the requirements for the service being billed. Current policy is that each client's services and progress are reviewed every 60 days from the previous plan.
When the service being billed is Targeted Mental Health Case Management, supervision must be conducted by a Licensed Mental Health Professional. An RN may be asked to consult on certain cases.
When the service being billed is Behavioral Health Home Sevices, supervision must be conducted by the Integration Specialist (Registered Nurse). An MHP may be asked to consult on certain cases.
When an individual receives Behavioral Health Home Services and a Mental Health Service (ARMHS, CTSS, EIDBI, or Psychotherapy) the supervision should be conducted jointly.
Depending on the service being billed, the following approvals/signatures on Assesssments Service Plans are required:
Case Managers at Accend must have bachelor's degree in one of the behavioral sciences or related fields including, but not limited to, social work, psychology, or nursing and have at least 2,000 hours of supervised experience in the delivery of services to adults with mental illness.
A case manager must receive regular ongoing supervision and treatment supervision totaling 38 hours per year of which at least one hour per month must be treatment supervision regarding individual service delivery. The remaining 26 hours of supervision may be provided by a case manager with two years of experience.
A Case Manager Trainee is a Case Manager with a degree without 2,000 hours of supervised experience in the delivery of services to adults with mental illness. A trainee is not an associate, but must:
There are various qualifying criteria defined for non-degreed Case Manager associates defined in Minnesota Statute 245.462. These include the following mentoring and continuing education, supervision, and mentoring requirements:
*A "case management mentor" means a qualified, practicing case manager or case management supervisor who teaches or advises and provides intensive training and treatment supervision to one or more case manager associates. Mentoring may occur while providing direct services to consumers in the office or in the field and may be provided to individuals or groups of case manager associates. At least two mentoring hours per week must be individual and face-to-face.
Registered Nurse with 4 year BA or BS degree. The Integration Specialists meets regularly with the Integrated Care Managers, meets all Behavioral Health Home recipients, reviews the Health and Wellness Assessment and co-approves the Integrated Care Plan and subsequent updates along with the mental health Treatment Supervisor.
A case manager as defined in Minnesota Statutes, section 245.4871, subdivision 4 (excluding paragraph a), and Minnesota Statutes, section 245.462, subdivision 4 (excluding paragraph a), or
A mental health practitioner as defined in Minnesota Statutes, section 245.4871, subdivision 26 or Minnesota Statutes, section 245.462, subdivision 17
The Behavioral Health Home specialists partners with a Behavioral Health Home Specialist to provide the supports identified in the Health Action Plan, reporting progress and results, and identifying new needs or concerns to the team.
Health Home Specialists will assist Navigators in implementing the supports identified in the Health Action plan, including helping individuals prepare for and attend appointments, teaching self-advocacy skils and Heath and Wellness education. Advocating on behalf of individuals as needed to obtain necessary medical care.
Qualifications for the role include:
A community health worker as defined in Minnesota Statutes, section 256B.0625, subdivision 49
A peer support specialist as defined in Minnesota Statutes, section 256B.0615
A family peer support specialist as defined in Minnesota Statutes, section 256B.0616
A case management associate as defined in Minnesota Statutes, section 245.462, subdivision 4, paragraph (g) or Minnesota Statutes, section 245.4871, subdivision 4, paragraph (j) (unless the individual is a Mental Health Practitioner and therefore qualifies as a Systems Navigator)
A mental health rehabilitation worker as defined in Minnesota Statutes, section 256B.0623, subdivision 5, clause (4)
A community paramedic as defined in Minnesota Statutes, section 144E.28, subdivision 9, or
A certified health education specialist
The Behavioral Health Home Service Coodinator provides a central point and contact and communication for individuals served, provider staff, and community parnters, maintains medical records, promotes and coordinates rapid response to referrals, and reports on quality assurance priorities identified by the team and agency.
Conduct intake interviews and brief needs assessments with referrals when Systems Navigators are not available.
Monitor referrals from referral to engagement, and all necessary assessment and planning. Report weekly to the Integration Specialist, Program, and Executive Director on referrals and engagement.
Receive and maintain medical records, transcribing applicable elements to the TabsTM EHR, and notify provider staff when key records are received.
Develop an articulate health and wellness vocabulary that will engender confidence in providers of health care and social services to the individuals we serve in common. Nurture positive and productive partnerships with providers with proactive communication and by providing information and education about the Behavioral Health Home Service, its purpose, goals and benefits to persons served.
Receive, route calls, and forward information from individuals served when they are unable to reach provider staff.
Facilitate coordination with the consumers’ Minnesota Health Care Programs (MHCP) managed care plan, if applicable.
Provide quality assurance reports at intervals identified on quality assurance goals and objectives for the Behavioral Health Home Service.
Maintain certification as a MNSure Navigator and assists individuals with maintaining health insurance.
The Service Coordinator will have at a minimum, the qualifications of a Qualified Health Home Specialist. Experience or training as a Health Unit Coordinator is a plus.
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May 19, 2022:
1) Add-ons standardized and explained in more detail.
2) Scheduled Service No Show with Travel added to non-contact service list as a billable service for Case Management.
November 28, 2022:
Eliminated reference to the Service Intensity Assessment in required assessments.
January 19, 2023:
Language corrected in required assessments for BHH: annual DA not required.
February 14, 2023:
Supervision of ICM Services clarified.
March 28, 2023:
Process for Initiating BHH services clarified to require Authorization forms prior to eligibility review.
May 1, 2023:
Language clarification in eligibility table. No change of rules.
January 25, 2024:
Correction to requirement for updates to the Diagnostic Assessment for Case Management. A update to the DA is required only every three years.
June 11, 2024:
Broken links to external resources for Immunizations and Preventative Health Care fixed.
Links to other obsolete guide sections removed.
Clinical Supervisor/Supervision replaced with Treatment Supervisor/Supervision to align with uses of this phrase in other services
August 22, 2024:
Functional and Health and Wellness deadlines for updates clarified based on July 1, 2024 statutory changes (updates required every 365 days after the full Functional or Health and Wellness assessment, where previously this was every 6 months).
September 19, 2024:
BHH and CMGT Intervention While Initiating notes changed to simply Intervention. Instructions clarified as applicable for other interventions.