Comprehensive Guide to Short-Term Residential Treatment Program (STRTP) Documentation Training

Short-Term Residential Treatment Program (STRTP) CYPBH Documentation Training Guide AQIS Support Team July 3, 2020

Medical Necessity Included Mental Health Diagnosis The diagnosis must be a Medi-Cal covered diagnosis An Included Diagnosis List can be found on the 2019-20 APT Resources link on the top right hand corner Types of Impairments and Examples Living Situation At risk for loss of placement. Unable to be reunited due to physical and verbal aggression due to her trauma abreactions. Has a tendency to AWOL when overwhelmed with conflicts. Financial Mgmt. Bipolar minor who is spends all his/her money Social/Communication Severe verbal and physical aggression with caregivers and foster siblings Daily Activities Refusal to take care of hygiene and is malodorous which impacts his/her ability to develop friends Educational/Vocational At risk for failing school, being retained for tardiness and poor attendance Legal Dependent of court and at risk to be ward of court due to recent shoplifting. On 6 month probation Substance Abuse Alcohol, Cannabis and poly-substances Mental Illness Management Due to mental illness, not able to take meds. consistently resulting in unstable moods Interventions Reducing the Impairments (Care Plan) Your care plan should be consistent with the assessment findings Interventions should look to ameliorate the MH condition and work towards stepping down from the STRTP to a lower level of care

Assessment (MH Program Approval Section 6) Assessments need to be completed within 5 calendar days from the date the client is referred to the STRTP program The completed assessment must be reviewed and signed by a LMHP Conducting your own assessment or Accepting a prior assessment You may conduct your own assessment or choose to use an assessment completed 60 days prior to the client s arrival to the STRTP If you use a prior assessment, it must be: Conducted or certified by an Interagency Placement Committee (IPC), or Completed by a LMHP, or Completed by a recognized provider of mental health services acting within their scope of practice

Assessment Elements A completed assessment must include all of the Medi-Cal required elements listed below: 1. Presenting Problems 2. Relevant conditions and psychosocial factors 3. History of trauma and exposure to trauma 4. Mental Health history 5. Medical History 6. Medications 7. Substance exposure and substance use 8. Client strengths 9. Risks 10. Mental Status Exam 11. Completed ICD-10 Diagnosis

Assessment for Emergency Placement (MH Program Approval Section 6) Emergency Placement Examples: Interagency Placement Committee could not meet and make a referral to an STRTP that best fits the client s needs Or, several STRTPs may be at capacity and the client had to be placed at an STRTP that had an opening, even if the STRTP program is not the most ideal fit for the client The client must have a 1 to 1 observation at all times or be in a physically separated area from all of the other clients while being assessed until deemed appropriate for the STRTP Emergency Placement Assessment needs to be completed within 72 hrs. LMHP must make a written determination that the minor meets the criteria for an STRTP

Admission Statement (MH Program Approval Section 7) The Head of Service affirms within 5 calendar days after completing the MH Assessment or 3 days for an Emergency Placement if the client meets the criteria for the STRTP in an Admission Statement These are the elements of the Admission Statement The assessment has been conducted and reviewed by a LMHP The safety of the client and other admitted children are considered The client does not require inpatient care The client meets medical necessity The client has been assessed for SED The client has been assessed for an Emergency Placement if required The client has been assessed for requiring the level of services of the STRTP

Needs & Service Plan (NSP) vs. Care Plan (CP) (MH Program Approval Section 8) The NSP and CP is reviewed and signed by a licensed mental health professional or the head of service or any other related discipline designated by the head of service within 10 calendar days of the child s arrival at the STRTP Needs & Service Plan Is historically a Social Services plan The NSP might relate to general needs such as housing, school, etc. The NSP is generally developed through a collaborative process during the Child and Family Team meeting process Care Plan CP are more specific to Medi-Cal requirements and Specialty Mental Health Services Goals should be congruent to the mental health assessment and impairments Goals should address the mental health condition and work towards a lower level of care I.E. stabilizing the child s aggressive behaviors in order to reunify with his/her parents

NSP and Care Plan cont. (MH Program Approval Section 8) Requirements Completed, reviewed and signed by a LMHP, HOS or related discipline designated by the HOS within 10 calendar days Identify specific goals to treat (behaviors, symptoms, impairments that are measurable) Transitional Goals identifying readiness to transition to an alternative tx. setting Documentation includes the client s participation/agreement with the NSP/CP Obtaining signatures from the required parties on the NSP/CP authorizes services Client s refusal to sign the Care Plan should be documented Attempts made to involve/obtain social worker s signature should be documented if there is difficulty with coordination The NSP/CP should be reviewed every 30 days by a MH program staff documenting progress towards the goals

Interim Care Plan (ICP) MH services should not be provided until an assessment and care plan is completed and signed by the required parties Continued attempts to obtain signatures should be made even if there is refusal to sign by the client or coordination issues arise with the SW. These should be documented. In the case of needing to provide immediate treatment before an assessment and care plan is completed and signed, an ICP may be completed and put in place for immediate services (i.e. psychiatric service, groups, etc.) The ICP documentation must establish that there is medical necessity (included diagnosis, impairments and interventions to reduce the impairments)

Clinical Review Report & Transition Determination (MH Program Approval Section 13) Clinical Review Report & Transition Determination This review is completed by a LMHP every 90 days This 90 day review is a more in depth clinical review of the client s progress in treatment vs. the 30 day review required for the NSP/CP This report determines the client s status and progress in treatment to determine whether he/she should remain in the program or transitioned to a different level of care Any transition determination is made in consultation with the placing agencies, if applicable The report includes: Summary of the types of services, frequency and impact on the goals Consideration of input from the or outside sources about the child s mental health Justification for continued stay or transition based on LMHP s clinical opinion

Progress Notes & MH Treatment Services (MH Program Approval Section 9 & 12) Progress Notes are to be completed within 72 hours of the service provided SIROP note format used for Individual, Collateral and Group Notes Symptoms Brief description of MH issue, Dx, Sx, Impairments Medical Necessity (Today, client presents as, complaints are, mood is ) Intervention Intervention(s) should address the presentation and the Care Plan goals Response How did the client respond to your intervention Cooperative, Guarded, Quotes from the client or parent Overall Progress What type of progress is the client making towards the goals Plan Based on this service, state what your plan is moving forward (ie. will coordinate a psychiatric evaluation due to increased agitation)

Progress Notes & MH Treatment Services (MH Program Approval Section 9 & 12) Intensive Care Coordination (ICC) and Case Management (CM) Progress Notes PIP Format Purpose Identify the purpose of the ICC or CM service Intervention Identify who you consulted or coordinated services with. Document what information was exchanged from you or what you were informed about. Document linkage or referrals and how it relates to the CP or will be beneficial in addressing the client s mental health condition. Plan Document what you will be doing with the information you obtained. Will you consult with the psychiatrist based on the new information you gathered? Will you call for a CFT meeting to address current concerns and placement issues? Will you consult with the collateral therapist about the how their style of communication triggers the client to feel angry? Will you work with the client on managing his anger during the next visit?

Progress Notes & MH Treatment Services (MH Program Approval Section 9 & 12) MH Services are targeted and planned unless it s a crisis Relate the focus of your interventions back to the Care Plan Passive vs. Active Interventions Passive - Listened, observed, empathized, agreed, encouraged Active Identified triggers resulting in the child s verbal escalation. Reviewed and role played the active steps of stop, think and respond using various real life scenarios until the child felt confident he/she could comfortably verbalize his/her emotions without yelling. Vague interventions Examples Writing provided coping skills, addressed client s anger, using play therapy, etc. are examples of vague interventions Be specific in detailing what intervention was used and how this helps reduce the client s mental health condition

Types of MH Treatment Services (MH Program Approval Section 12) Types of Services and CPT Codes Assessment {90899-6} Individual Therapy {CPT 90832 (16-37m), 90834 (38-52m), 90837 (53+)} Collateral Therapy {CPT 90846} Group Therapy {90853} Case Management {908991-1} Intensive Care Coordination (ICC) {90899-151} Intensive Home Based Services (IHBS) {90899-154} Rehab Individual {90899-17} Rehab Family {90899-157} Rehab Group (Group Education) {99708} Crisis Intervention {90899} Crisis Psychotherapy {90839} Medication Support {99212 (10-39m), 99213 (15-44m), 99214 (25-54m), 99215 (40-69m)}

Types of MH Treatment Services cont. (MH Program Approval Section 12) Assessment Progress Notes Should be about gathering information to identify medical necessity in order to come up with information to complete your MH Assessment Do not blend notes with other services such as including individual therapy or case management interventions in your notes Individual/Collateral/Group Therapy Progress Notes The interventions for these type of MH services should be related to the Care Plan goals Not relating the intervention(s) back to the CP goals puts the note at risk for Medi-Cal recoupment Intensive Care Coordination (ICC) vs. Case Management (CM) Progress Notes Both of these services are used to code for consulting, coordinating, planning, referring, linking and monitoring the client s progress ICC is intended for children involved in multiple systems, requires cross-agency collaboration and have more intensive needs ICC services requires a CFT to be in place to drive the services The CFT helps to coordinate, collaborate and identify what the client s service needs are

Types of MH Treatment Services cont. (MH Program Approval Section 12) Criteria for a Crisis: A crisis is an unplanned service lasting less than 24 hrs. and requires a timely response There is a level imminent danger to self, others or the client is gravely disabled Documentation addresses: The presenting issue or situation that justifies that this is an unplanned activity and requires immediate attention due to the imminent danger to self, others or the client is gravely disabled Mental Status Exam Risk Assessment Interventions documenting attempts to resolve the crisis Diagnosis Disposition

Types of MH Treatment Services cont. (MH Program Approval Section 12) Crisis Intervention Must meet the elements that trigger a crisis as defined previously Documentation in the progress note must include all the elements defined previously The service may be face to face or over the phone The disposition may result in a psychiatric hospitalization or the crisis may be resolved The maximum number hours that can be claimed per 24 hours is 480 min. (8 hrs) for a crisis service Do not bill for waiting (i.e. waiting for CAT to arrive) Crisis Psychotherapy This is a planned service that becomes an unplanned crisis Is only coded when a Face to Face service is provided (not over the phone) Must be licensed to provide a Crisis Psychotherapy service A MHW cannot provide Crisis Psychotherapy as it is deemed out of scope of practice

Types of Mental Health Services cont. (MH Program Approval Section 12) Intensive Home Based Services (IHBS) vs. Rehab Services (Ind., Collateral, Group) IHBS/Rehab interventions are aimed to: Help the client build skills for successful functioning in the home and community Also designed to help the family s ability to help the child successfully function in the home and community Is provided predominantly outside of the office setting (i.e. home, school, community) but not limited to Other service activities may include, but not limited to those listed below. Functional skills Daily living skills Social and leisure skills Grooming and personal hygiene skills Support resources Medication education Note: The important concept to remember is how the client s mental health condition has impaired their functioning and what you teach the client will help to restore those skills.

Non-Billable Activities Lockouts AWOL, Juvenile Hall, Psychiatric Hospitalization Blending PN (The CPT code & service documented must match) Reviewing Charts Transporting a client Filling out forms No Shows Supervision Researching Recreational Socialization Clerical (i.e. faxing, copying, scheduling)

Transition Determination Plan (MH Program Approval Section 10) Transition Determination Plan is similar to a discharge summary It is developed, completed and signed by a member of the MH program staff before the client transitions out of the STRTP Copies of the Transition Determination Plan should be provided to the parent, guardian, conservator or person(s) identified by the court to participate in the decision to place the client

Transition Determination Plan cont. (MH Program Approval Section 10) The Transition Determination Plan Includes: Admission reason Transition reason (i.e. goals met therefore transitioning to a lower level of care or an alternative level of care is needed as the current STRTP placement is not a fit) Course of mental health treatment at the STRTP (ie. types of services, meds, etc.) Diagnosis at time of transition Non-MH services provided during STRTP stay (i.e. medical and dental) Aftercare Plan Diagnosis and follow up plan Medication(s), including side effects, dosage schedule Goals and expected outcomes Relevant treatment recommendations Educational information, grade level functioning, special education needs Referrals to medical and mental health providers Other relevant information

Medication Control and Monitoring (MH Program Approval Section 11) A prescribing physician shall examine the prior to prescribing any psychotropic medication and include a screening to determine whether there are any potential medical complications that may contribute to the client s mental health condition. This shall be noted in the client s chart. A written medication review is completed at least every 6 weeks and signed by the prescribing physician The written review can be prepared by a MH program staff member acting within their scope of practice (i.e. LPN, LVN, RN) but the prescribing physician must sign Includes side effects, efficacy, med. compliance, justification to cont. or change meds, medication treatment should be consistent with the Care Plan goals A psychiatrist will review the course of treatment for all client s who are not on psychotropic medications at least every 90 days and include the review in a progress note

Resources Annual Provider Training 2019-2020 Sample notes (Assessment, Individual, Collateral, Crisis Psychotherapy, Collateral Rehab, IHBS and ICC) Reasons for Recoupment information Included Diagnosis List QRTIPS AQIS s monthly tips and guidance on various documentation issues Pathways to Well-Being / Intensive Services (AQIS-CYPBH Support) http://www.ochealthinfo.com/bhs/about/cys/support/pathways MC Manual for ICC/IHBS/TFC Services 3rdEdition (DHCS) Integrated Core Practice Model (ICPM) Guide (2018) PWB/IS Eligibility Assessment Screening Form 90 Day Tracking Sheet for 90 day reviews Orange County s PWB Documentation & Training Guide (CYPBH) Other Power Point trainings on PWB

STRTP Contacts Tim Hoang, Psy.D., AQIS CYPBH Support 714-796-0146 thoang@ochca.com Alice Kim, LMFT, STRTP Program Manager I 714-796-8285 alkim@ochca.com Goli Hooshvar, Ph.D., LMFT (STRTP Contract Monitor) 714-796-0115 ghooshvar@ochca.com Bao Chau Nguyen, LMFT (STRTP Contract Monitor) 714-834-5610 banguyen@ochca.com