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Integrated Care Management - CMGT and BHHS



Welcome to Integrated Care Management

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.

Goals of Integrated Care Management

The goals of Integrated Care Management are to:

Referral and Eligibility

Who is Eligible for Our Integrated Care Management Services?

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

Eligibility Screening for Adult Mental Health Targeted Management Services

Adult Mental Health - Targeted Case Management Services require Eligibility Screening, as follows:

  1. If the referred is a new client and has had an Adult Diagnostic Assessment within the previous 180 days indicating a recommendation for AMH-TCM.
  2. If necessary in a case where the referred's history is unclear from the DA interview, and more information is needed to establish eligibility, using necessary ROIs, obtain proof of eligibility in the form of:
  3. Those parts of the Eligibility Screening that are pulled automatically from the DA will not appear until the DA is approved. This should occur within 7 days of the interview. Your responsibility as a Case Manager is to monitor this and assure that the deadline is met. Once the DA is approved, tap Refresh Assessment Data on the Intake FA or Case Management Elibility Screening to fetch this information from the DA.
  4. Complete the rest of the FA or Case Management Eligibility Screening and save it as Complete. Your treatment supervisor will receive an automated message through the TabsTM EHR system that the screening is complete and ready for review and approval.
  5. Follow-up within a few days to ensure that your treatment supervisor has reviewed and approved the Eligibility Screening.
Eligibilty Screening Validity

And eligibility screening for Case Management is required only every three years and is valid for three years.

What is SPMI (For Purposes of Case Management Eligiliibty)?

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:

  1. has been hospitalized for symptoms of mental illness twice (or more) in the last two years; or
  2. has been in treatment for more than six months in the past year; or
  3. has been treated by a crisis team two or more times within the last two years; or
  4. has a diagnosis of schizophrenia, bipolar disorder, major depression, schizoaffective disorder, or borderline personality disorder; and
  5. has, in the last three years, been committed by a court as mentally ill or has had a stay of commitment; or
  6. was eligible under one of the criteria above, but is still at risk of hospitalization or treatment, and has a statement from a mental health professional describing the risk (as in #4 above); or
  7. was eligible for case management as a child and is age 21 or younger.

Use the following flowchart to determine eligibility for Case Management services:




Special Instructions for County-Specific Referrals to Case Management

UCARE Clients Who Are Residents of Counties Other Than Lake and St. Louis

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.

Residents of Any County Other Than Lake or St. Louis

Ask your Program Manager for permission to initiate AMH-TCM services for residents of other than Lake and St. Louis Counties.

Carlton County

We do not provide AMH-TCM services to residents of Carlton County without prior notification to Carlton County.

Lake County

Lake County Residents and Case Management Referrals:

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.

St. Louis County Residents on Medical Assistance (non-PMAP/MCO)

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:

St. Louis County CMGT Notification Form

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:

  1. On your iPad, Navigate to the form online and then tap the share/send button in your browser. (Blue box with an up arrow.)
  2. Choose Mail, and the form will attach itself to an email. (If you have an email account other than your work email on your device, verify that you are sending it from your work email address and that your device email has your Zix encryption signature on it.)
  3. Tap on the form and select Markup from the menu.
  4. Complete the form by tapping in the text areas and typing, or tapping checkboxes and radio buttons to select.
  5. When you are ready to sign, tap the pen tool on the top right of the screen (blue circle with the tip of a pen icon).
  6. Select a pen and ask your client to sign with finger or stylus.
  7. Add your own signature and close the pen tool
  8. With the pen tool closed, you can add dates to the signatures by tapping on the date fields and typing the date.
  9. Tap Done on the upper right of the form
  10. Send/forward the email to medicalrecords@accendservices.com for faxing to St. Louis County and uploading to the client's file.
  11. Offer to provide the client with a copy of the Rights Notification, and inform medical records to print one for you or mail it if they ask for one.
What to Do When a Client Moves to a County Where We Can No Longer Provide Case Management

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.

What to Do When a Client Is Eligible But We Cannot Provide Case Management Services Because of the Payer

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 for Admission to Integrated Care Management Services

  1. Immediately following a DA interview, or receipt of an external DA that results in a recommentation for either Case Management or BHH services, meet with the referred individual to assess basic needs and make plans for meeting these needs.
  2. During the intake interview, schedule a follow-up meeting date, time, and place to respond to the needs the individual has identified.
  3. Using the information in the DA, complete required forms and document listed below for the specific service and submit them for approval.
  4. While responding to the referred indivdual's basic needs, begin collecting information for the Intake Integrated Functional and Health & Weillness Assessment and Integrated Plan.
  5. Assure that the DA is completed and approved (or external DA is reviewed and approved) within 7 days of intake.
  6. Complete the Intake Integrated Functional and Health & Weillness Assessment and Integrated Plan within 30 days of admission.
  7. During the intial 30-day assesssment period, obtain ROIs for healthcare providers and send for applicable medical records, or, with the individual, review medical records online. Instructions for doing this for Epic EHR systems can be found in our Medical Records guide.
  8. Update the Integrated Functional and Health & Weillness Assessment and Integrated Plan within 90 days of admission with more detailed information gathered over the first 90 days of service.

Intake Process and Requirements, Assessment and Planning Deadlines

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

Core Integrated Care Management Services

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:

First: Maintain Health Care Coverage

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.

Assessment

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.

What You Will Learn

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.

Assessment Types

The Adult integrated Functional and Health and Wellness Assessment

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:

Client Status Assessment

A Client Status Assessment is required within 30 days of admission and every 180 days thereafter.

Child Health and Wellness Assessment

For children, we use the Basic Needs and Child Health & Wellness Assessment and Crisis Response Plan.

The Assessment Process

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:

Using Health Care and Other Referrals and Action Lists

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.