Referral and Intake Procedures

Goals and Objectives

Goal

The people we serve do not come to us anticipating a need for help weeks or months from now. They come to us because they are experiencing a mental health crisis or some other urgent problem that is related to mental health. Our goal is: no waiting lists. We want to initiate services to all referrals as quickly as possible.

Objectives:

• Callers are processed and receive an appointment during the call, by the person who answers the phone.
• Callers receive an intake appointment, including a Diagnostic Assessment Interview, if needed, within one week of the call.
• Walk-ins receive a same-day intake and Diagnostic Assessment Interview.
• All referrals receive their first service on the same day or within two days of the final Diagnostic Assessment Interview in which eligibility for service is determined.

Your Responsibility

Your responsibility is to help us achieve these goals and objectives.

If you provide intake interview services, you will start services on the day of intake and/or schedule a first appointment in the next two days. If you do not have a primary to whom you can assign the referred, you will act as primary for initiating services and schedule the follow up with yourself.

When you receive a referral, you should already be scheduled for an appointment. You will communicate your availability for new referral appointments by using the scheduler and blocking out times as Open for Scheduling or Referral. If you receive a referral without a scheduled appointment, you will call the referred that same day and make an appointment within the next two business days, unless the individual prefers later.

See individual services for eligibility and intake requirements.

Information Gathering During the Referral Call

Begin with a few brief needs assessment questions:

• Who referred you to us? Why?
• What services are you seeking (if known)? Open Service tabs for the services they have identified, if any.
• Get address, phone and other contact information.

• determine whether or not the individual has mental health services elsewhere, and if they have a recent DA (if so, we may be able to use that DA for admission)
• determine whether or not the individual has active insurance to cover services
• determine whether or not the individual will be able to consent for treatment (or has a guardian)
• ask whether or not the individual is able to come to the office for the intake , or needs us to go to their home

Uninsured Referrals

When the referred is not insured, offer to schedule an appointment with a MnSure Navigator, and make that appointment within one week as well

Environmental and Safety Screening for In-Home Services

When asked to conduct the intake interview in the individual's home, conduct a brief Environmental and Safety Screening using these questions:

• Do you live with others? (With whom? How many? Is there a private space where staff can meet with you?)
• Do you have any pets? (What kind? If dogs, cats or other ambulatory animals, can you secure them in a kennel or other room if necessary?)
• Are there unsecured guns in the home?
• Are there any safety concerns in your home for our staff members when they visit?
• Do you live in a secure building? How will we gain access?
• Are there any other instructions needed for our practitioner to find or access your home or apartment?

County of Financial Responsibility

County of Financial Responsibility must be entered for all new clients. This is different from County of Residence.

County of Financial Responsibility (COFR) is the county that a client has established residence by living in private housing for at least two full months.

Clients who live in Excluded Time Facilities do not establish a new COFR. Excluded time is time a client spends in:

• Hospitals
• Sanitariums
• Nursing homes
• Halfway houses
• Foster homes
• Board and care homes
• Maternity homes
• Domestic violence shelters. Also see 0011.06.03 (State Residence - Excluded Time), 0011.06.09 (State Residence - 30 Day Requirement).
• Correctional facilities
• Regional treatment centers

The COFR for residents of these facilities is the county where they resided prior to the placement. However, sometimes, counties mutually agree to change the COFR to the host county when the placement will be long term. Always confirm the county of financial responsibility for and residents of these facilities. Typically, if the client does not know, the facility will.

Documentation

Document the pre-DA portion of the Intake Interview as Intake or Referral Interview, found in Other Notes.

After the DA Interview (for referrals to Case Management, Behavioral Health Home Services or ARMHS):

• Explain the services that the Diagnostician has recommended.
• • If Case Management or Behavioral Health Home Services are recommended, and the individual choose to receive this service, and has insurance that covers it, initiate these services immediately.
  • Complete the intake interview portion of the Adult Intake Functional Assessment, and document this activity using the corresponding Assessment/Planning Interview note type for the service the individual has chosen.
  • Change the status of the individual for that service to Initiating.
• If neither Case Management or BHHS is recommended or is chosen by the individual, but ARMHS is, initiate ARMHS in the same way.

Missed Appointments for Intake Interviews and Diagnostic Assessments

When clients do not arrive for scheduled intake interviews/diagnostic assessment follow the procedures in the chart below under Disengagement Procedures.

Consent for Services/Treatment

While it is considered a best practice to obtain written consent for services, an individual or legal guardian may demonstrate approval/consent with a written signature, secure electronic signature, or documented oral approval.

*References: Mn Rule 2150.7525, Mn Statute 245I.02 and BHH Services News and Information, Date: July 3, 2024

Obtain Demographics Information

For all intakes, complete the demographics information found in the client info section of Tabs^TM. We use this information in a variety of reports to the state, funders, and for internal reports.

Service Eligibility Summary

Use the following chart as a quick guide for eligibility for each of the services we provide. See the guides for specific services for more detailed information.

Service	Eligibility Criteria	Available to residents of:	Required Health Plans
Adult Case Management	Diagnosis of SPMI   , recent history of hospitalization or treatment, or statement of risk of hospitalization or treatment by a mental health professional. View more here	Lake County St. Louis County Other counties depending on payer. See important instructions for residents of specific counties in the Case Management Guide, here and seek advice from the billing department before initating case management services.	Managed Care MA or Minnesota Care through: Blue Cross Blue Shield, Health Partners, Medica, or UCare or Medical Assistance in Lake and St. Louis Counties only.
Adult Rehabilitative Mental Health Services	Adults diagnosed with Serious or Serious Persistent Mental Illness. The MHCP manual does not define how recent a Diagnostic Assessment must be for admission to ARMHS. However, best practice is that ARMHS is only started if justified by a review of a DA that is less than one year old. View more here	Any county where we have capacity. Generally county of our local office or neighboring counties.	Medical Assistance or MinnesotaCare with any payer.
Behavioral Health Home Services	Adults with SMI and Children with SED and other disabilities. BHH may start without a DA with a qualifying Diagnosis from a health professional but the DA must occur in the next six months. View more here	Any county in Minnesota	Medical Assistance including PMAPs. *MinnesotaCare does not cover BHHS.
Children's Therapeutic Supports and Services	Children diagnosed with Emotional Disorders or Mental Illness by a DA that has been completed within 1 year of admission. and impaired functioning (we use the CASII/ECSII for this.)  View more here	*Includes CTSS Psychotherapy. Any county in Minnesota	Medical Assistance or MinnesotaCare with any payer.
Diagnostic Assessment and Clinical Professional Services	Anyone who requests one One session of Explanation of Findings may occur prior to the Approval of the DA following the interview.	Any county in Minnesota	Some private/commercial insurance, Medicare (if provided by licensed clinicians only, Medical Assistance or MinnesotaCare with any payer.
Housing Stabilization Services	Adults and Children with disabilities, mental illness or behavioral disorders, or seniors who are homeless, at risk of homelessness, inadequately-housed, or transitioning from a supported living or institutional setting to a more independent living setting. View more here	Currently for clients served out of our Duluth office. Application in process to add this service to our Minneapolis office.	*Medical Assistance including PMAPs. *MinnesotaCare does not cover HHS.
Psychotherapy Adult	Persons with a chronic or acute mental health condition requiring psychotherapy treatment as determined by a DA that is Approved and Signed by the third psychotherapy session.	Any county in Minnesota	Some private/commercial insurance, Medicare (if provided by licensed clinicians only), Medical Assistance or MinnesotaCare with any payer.
Psychotherapy Child	Children with a chronic or acute mental health condition or behavioral disorder requiring psychotherapy treatment as determined by a DA that is Approved and Signed by the third psychotherapy session.	Any county in Minnesota. *Do not use Psychotherapy Child for children enrolled in Minnesota Health Care Programs and eligible for CTSS.	Some private/commercial insurance. Medical Assistance or MinnesotaCare with any payer.

Adult Intake Interview and Process

ARMHS, Case Management, and Behavioral Health Home Services

We conduct intake interviews for all adults. Use the Adult Intake Assessment and Plan found in Service Plans along with the Adult Intake Diagnostic Assessment for an efficient intake assessment process. After completing this form, record the FA/HWA in the assessment template Record of FA/HWA from Combined Assessment and Plan using the appropriate. This will appear in either the FA or HWA list options.

Notifications Required

Notifications are required when initiating the following services with these specific payers:

Case Management- Residents of St. Louis County when the payer is Medicaid of Minnesota. Notifiy St. Louis County using this form.

ARMHS (including Medication Education and ARMHS Peer Specialist Services)- All ARMHS referrlals. 

For all recipients of UCare, also notify UCare using this form.

The requirement for notifying UCare of the initiation of ARMHS will no longer be required as of January 1, 2025.

Behavioral Health Home Services- Notify all payers using this form.

To ensure that these notifications are completed, these services require that you complete the form Notification of Adult Service Initation upon intake for these services regardless of the payer. Find this form in the clients menu > document > client forms > notifcations and prior authorizations.

After the Intake - Case Management

• Begin services immediately with a follow-up appointment within two business days of the intake and DA interview.
• Case Management services should begin immediatdely following the DA, with an emphasis on meeting basic needs.
• When Case Management services are recommended and requested by the referred individual, immediately begin the Eligibility Screening. Let the diagnostician know you will need the statement of medical necessity written immediately. Plan to complete the Eligibility Screening prior to the next appointment. Document this work as CMGT Eligibility Screening.
• Immediately following completion of the Adult Intake FA, begin work on the ICSP.

After the Intake - ARMHS

• When ARMHS are recommended and requested by the referred individual, immediately begin the Functional Assessment. Plan to complete the Functional Assessment within your first few visits. Document your work time with the individual as FA Initial Interview or Observation. Document time spent writing the FA as Functional Assessment Write up.
• During initial appointments, also concentrate on meeting immediate unmet needs identified in the Intake Interview. Functional Assessment and Eligibility Screening should not delay this work and helping with basic needs is an opportunity to gather information that informs the FA.
• Community Intervention (see the definition here)) on behalf of a referred person is the only service allowed in ARMHS prior to completion of the ARMHS Treatment Plan.

Child Intake

For intakes for children who will receive any service other than, or in addition to EIDBI, use the Child Intake Assessment and Plan, found in Service Plans. After completing this, if the child will receive BHH service, document the Basic Needs Assessment using the quick Record of Basic Needs Assessment found under that template type.

Assure that the DA is Completed On Time

For any service, the DA must be complete and approved within one week of the interview. Case Managers and Practitioners should monitor progress on the DA and remind the diagnositician to complete it by the required deadline. Once the Intake DA is approved, the Intake Asssessment and Plan can be approved on the same day.

Monitoring Responsive Services

Quality target: Referrals to each service are seen in a timely manner.

• No less than weekly, use a client search for clients in referral status for your assigned department. Include the following search criteria:
  • Primary: indicates to whom the client has been assigned.
  • Insurance: indicates whether or not the client's insurance remains active.
  • Referral Date: gives a date by which to assess responsiveness (the client should be seen within a week of this date).
  • Diagnostic Date: indicates whether or not the DA is complete (should be complete within one week of the interview).
  • Admit Date: use as a double check to make sure that the client has not been admitted and not moved to active status.
  • Last Seen: use to see if the client has been seen.
  • Last Note: use to see notes that indicate an effort to contact the client, such as Contact and Scheduling, or Client-Initiated Cancellation.
  • Referral Notes: use as a quick reference to refresh you on the details of the referral.
• Using this report, open all Last Seen entries. Confirm that the client has been seen and if so, move the client to the following status:
  • For ARMHS: Initiating
  • For Case Management: Initiating
  • For CTSS: Active
  • For Psychotherapy: Active
• Enter the start date as the date the client was first seen and received services.
• Follow-up on all clients not seen. Contact the assigned team member for the service and make a note in the client's Referral Notes indicating what you learn, including efforts to contact and why the client has not been seen.
• For diagnostic assessments not complete, follow up with the diagnositician to ensure that the DA is complete before the client is seen for a second time.

Referrals For Additional Services During Intake

Quality target: Open the client for the right services, in the right order, and at the right time.

• Open the client with the status "Referral" for all services recommended and that they indicate they want to accept (excepting special circumstances described below).
• Schedules a follow-up appointment with Case Management or Behavioral Health Home within two days, if they have requested this service and are eligible.
• If the individual will recieve ARMHS, but not CMGT or BHH services, schedule the 2-day follow-up with and ARMHS provider.
• For children who appear eligible for CTSS, open the child as a referral for CTSS. Do not schedule an appointment for CTSS until the following are complete:
• • the diagnostic assessment,
  • service intensity assessment (CASII or ECSII),
  • applicable SDQs, and
  • Treatment Plan.
• For clients seeking Psychotherapy services, open the client as a referral and, if possible, schedule an appointment with a pscyhotherapist within the next two weeks..
• For each service, enter the primary and secondary insurance that will pay for the service.
• Enter the referral date as the date referred to the service.

Using Status To Monitor Client Admissions

Status	Service	Use When
Referrral	EIDBI	Use for all referrals to EIDBI services prior to the beginning of work on the CMDE.
Referrral	Clinical Professional	Use for all referrals when the DA is scheduled in advance and has not yet taken place (not for walk-ins).
Referrral	All Other services	Use for all referrals to all services recommended at the time of the DA interview. Clerk individuals from Pending status to Referral if the DA Interview indicates eligiblity.
Initiating	EIDBI	Use once the CMDE work has begun and until it is submitted to the payer for authorization.
Initiating	All other services	Use once the first service is delivered, and until all required assessment and planning work is complete. Do not use Initiating status for Clinical Professional. Once the DA work has begun, mark the status as Active
Active	EIDBI	Use once service have been authorized and have begun (first service).
Active	All other services	Use once all initial assessment and treatment planning work is complete. This is: No less than 30 days for ARMHS and Case Management No less than 60 days from the first service for Behavioral Health Home
Hold	All Services	Use only when services are active, but the individual has asked for a temporary break in services and we know the date, or have a reasonable idea when services will begin again. The move to Hold status should be accompanied by a Referral Note indicating the reason for the request for Hold status and the aniticipated restart date.
Closing	All Services	Use when an individual has disengaged from services (and typically when the individual is out of contact with us, and has received a We've Been Missing You letter) but the case is being kept open in case the individual responds to an invitation to re-engage.
Previous	All Services	Use when permanently closing services and the Discharge Review is complete.

Documenting Intake Activities

Activity	Note Type
Pre-DA Interview	Other Notes: Intake or Referral Interview
Post-DA follow-Up - clear service recommendation and eligibility	Assessment Interview for the applicable service
Post-DA follow-Up - no clear service recommendation or unclear eligibility	Other Notes: Intake or Referral Interview

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Discharge Procedures for Individuals Disengaged from Services

See specific service guides for normal discharge procedures. What follows is a summary of steps to take when you have lost touch with someone and have been unable to reach them.

For any service, if an individual is engaged with other services within the agency, coordinate with other providers to determine the reasons for disengagement and interest in continuing. Do not discharge individuals from the service from which they have disengaged, until someone from our agency has spoken with them and they have confirmed that they no longer want the service.

If you aren't able to reach someone using contact information you've been given, or previously used, you may want to send a short Trying To Reach You letter. This letter, and the We've Been Missing You letter described below are the only letters authorized for reaching out to disengaged individuals.

When an individual has disengaged from all services and cannot be reached by phone or at the residential address where we typically meet them, do the following before proceding with discharge.

Disengagement Procedures

Service	Steps to Follow
Referrals who fail to attend Intake Interview/DA	Call the client. Document Contact & Scheduling Related to CCN. If you reach the client, offer a rescheduled appointment. If able to leave a message, leave one and inform the office. They will try to reach the client two more times. If they do not hear from the client they will move to unserved and write a Referral Moved to Unserved note. If unable to leave a message, inform the front office to move the client to unserved. Write a Referral Moved to Unserved note.
Referrals who fail to engage following an intake Interview/DA	Attempt at least 1 contact weekly for 4 weeks. If there are compelling reasons to continue efforts beyond 4 weeks, please do so. If no contact by 4th week, send a Trying To Reach You letter and move to Unserved. Write a referral note after each contact with result as well as when we move to Unserved so it's easy to track process.  When moving to Unserved status, describe why in the note section of the service record. Write a Referral Moved to Unserved note.
Adult Mental Health Targeted Case Management Disengagement	Contact other providers for whom you have signed Releases of Information in an effort to determine the individual's whereabouts. Make and document at least weekly efforts to contact and schedule for the first 6 weeks, and at least monthly thereafter. Debrief on the case during your next scheduled monthly supervision and document the debriefing in a File Note. After two months, if the individual is not engaged with any other services, send a We've Been Missing You letter to the individual's last known address inviting the individual to contact us. Complete a Status Assessment recording last known status. Change the individual's status for Case Management services to Closing. Continue monthly efforts to contact until the closing date arrives Two weeks before the planned closing date arrives and we have still not heard from the individual, send a second We've Been Missing You letter to the last known address, again inviting them to contact us if they wish to continue services Hearing nothing, complete a Discharge Review and change status to Previous. If the individual receives no other services from Accend, close Clinical Professional services by changing status to Previous.
Adult Rehabilitative Mental Health Services Disengagement	Contact other providers for whom you have signed Releases of Information in an effort to determine the individual's whereabouts. Make and document at least weekly efforts to contact and schedule for at least one month. Debrief on the case during your next scheduled monthly supervision and document the debriefing in a File Note. After one month, if the individual is not engaged with any other services, send a We've Been Missing You letter to the individual's last known address inviting the individual to contact us. Complete a Status Assessment recording last known status. Change the individual's status for ARMHS services to Closing. Hearing nothing in the month that follows, complete a Discharge Review and change status to Previous. If the individual receives no other services from Accend, close Clinical Professional services by changing status to Previous.
Behavioral Health Home Services Disengagement	Contact other providers for whom you have signed Releases of Information in an effort to determine the individual's whereabouts. Make and document at least weekly efforts to contact and schedule for the first 6 weeks, and at least monthly thereafter. Debrief on the case during your next scheduled monthly supervision and document the debriefing in a File Note. After two months, if the individual is not engaged with any other services, send a We've Been Missing You letter to the individual's last known address inviting the individual to contact us. Change the individual's status for this service to Closing. Continue monthly efforts to contact until the closing date arrives Two weeks before the planned closing date arrives and we have still not heard from the individual, send a second letter to the last known address, again inviting them to contact us if they wish to continue services Hearing nothing, complete a Discharge Review and change status to Previous. If the individual receives no other services from Accend, close Clinical Professional services by changing status to Previous.
Children's Therapeutic Supports and Services Disengagement	Make and document at least weekly efforts to contact the parent or guardian and schedule for at least 4 weeks. If unable to reach them, contact other providers for whom you have signed Releases of Information in an effort to determine the individual's whereabouts. Debrief on the case during your next scheduled monthly supervision and document the debriefing in a File Note. After one month, if the individual is not engaged with any other services, send a We've Been Missing You letter to the individual's last known address inviting the individual to contact us. Change the individual's status for this service to Closing. Hearing nothing, complete a Discharge Review and change status to Previous. If the individual receives no other services from Accend, close Clinical Professional services by changing status to Previous.
Clinical Professional and Diagnostic Assessment	Close Clinical Professional Services on the date that the final other active service is closed.
Early Intensive Developmental and Behavioral Intervention	Make and document at least weekly efforts to contact the parent or guardian and schedule for at least 4 weeks. If unable to reach them contact other providers for whom you have signed Releases of Information in an effort to determine the individual's whereabouts. Debrief on the case during your next scheduled monthly supervision and document the debriefing in a File Note. After one month, if the individual is not engaged with any other services, send a We've Been Missing You letter to the individual's last known address inviting the individual to contact us. Change the individual's status for this service to Closing. Hearing nothing, complete a Discharge Review and change status to Previous. If the individual receives no other services from Accend, close Clinical Professional services by changing status to Previous.
Housing Stabilization Services Disengagement	Make and document at least weekly efforts to contact the individual for at least 4 weeks. Contact other providers for whom you have signed Releases of Information in an effort to determine the individual's whereabouts. Debrief on the case during your next scheduled monthly supervision and document the debriefing in a File Note. After two months, if the individual is not engaged with any other services, send a We've Been Missing You letter to the individual's last known address inviting the individual to contact us. Change the individual's status for this service to Closing. Hearing nothing, complete a Discharge Review and change status to Previous.
Psychotherapy Disengagement	Make and document at least weekly efforts to contact the individual for at least 6 weeks. Contact other providers for whom you have signed Releases of Information in an effort to determine the individual's whereabouts. Debrief on the case during your next scheduled monthly supervision and document the debriefing in a File Note. After two months, if the individual is not engaged with any other services, send a We've Been Missing You letter to the individual's last known address inviting the individual to contact us. Change the individual's status for this service to Closing. Hearing nothing, complete a Discharge Review and change status to Previous. If the individual receives no other services from Accend, close Clinical Professional services by changing status to Previous.

Resources

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Updates to this Chapter

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April 29, 2023: Process added for referrals who fail to engage.

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April 29, 2023: Housing Stabilization Services added to service table.

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August 28 29, 2024: Instruction to not use Initiating status for CTSS when assessment and planning work begins is removed..

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September 19, 2024: Modfication and clarification of Discharge Procedures for referrals who fail to engage.

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September 30, 2024: Fine-tuning/clarification of language on required Notification of Adult Service Initation. No policy changes.

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October 3, 2024: Fine-tuning/clarification of language on referrals who miss intake appointments.

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October 14, 2024: Clarifications to eligibility table all services.

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October 30, 2024: Language added to clarify that consent for services may be verbal or in writing.

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