completing a comprehensive intake · • can be either for physical health, mental health, or both...

Completing a Comprehensive Intake

June 2017

Objectives: After this training you will be able to

• Identify what an intake is

• Identify who can complete an intake assessment

• Identify what areas need to be addressed during intake

• Understand member rights and directives

• Understand the importance of risk assessment

• Identify how to assist members in locating a Primary Care Provider

May 2017Completing an Intake2

What is an Intake?

• Initial face-to-face encounter in which the provider obtains information from the individual, and parent/caregivers or other family members

• Serves to gather information to assess the needs and preferences of the individual as it relates to the delivery of a specific service

• Introduces the family to services, obtains consent for treatment/services, and educates on member rights and responsibilities

May 20173 Completing an Intake

What is an Intake?

At a minimum, all provider intakes should include the following:

• A comprehensive assessment

• A mental health risk assessment

• A review of Human Rights and HIPAA

• Discussion of Provider Choice

• Discussion of whether the member has a Primary Care Provider

• Consent to Exchange information

• A fall risk assessment

• Discussion of Advanced Directives


Keys to a Comprehensive Assessment

May 2017Service Specific Provider Intake

5

What is an Assessment?

• An assessment is a face-to-face interaction in which the provider obtains information related to the member’s mental health status

• Some services require a Service-Specific Provider Intake (SSPI) to be completed as the assessment*

• The provider assessment must be completed annually for all services or more frequently as service needs change

• Provider assessments are required prior to developing an Individual Service Plan (ISP)

• Assessment is always ON-GOING


*See chapter 4 of the Community Mental Health Rehabilitative Services (CMHRS) Manual for services that require an SSPI.

Who Can Do An Intake Assessment

Intake assessments for all Mental Health Services must be conducted by a licensed mental health professional (LMHP) or LMHP Type.

LMHPs include:

• A Physician or Psychiatrist

• Licensed Clinical Psychologist

• Licensed Clinical Social Worker

• Licensed Professional Counselor

• Licensed Psychiatric Clinical Nurse Specialist

• Licensed Marriage and Family Therapist

• Licensed Substance Abuse Treatment Practitioner

• Licensed Psychiatric Nurse Practitioner (substance use services only)

• Licensed Behavioral Analyst (behavioral therapy only)


Who Can Do An Intake Assessment Cont.

LMHP “Types” Include:

• LMHP-Supervisee in Social Work (LMHP-S)

• LMHP-Resident in Counseling (LMHP-R)

• LMHP-Resident in Psychology (LMHP-RP)

• Certified Substance Abuse Counselor (CSAC) under supervision of a licensed provider (substance use services only)

• Certified Substance Abuse Counselor-Assistant (CSAC-A) under supervision of a licensed provider (substance use services only)

• Licensed Assistant Behavioral Analyst (LABA) under supervision of a LBA (behavioral therapy only)


What to Include

A comprehensive assessment for any mental health service should include the following:

• Presenting Issue(s)/Reason for Referral

• Behavioral Health History/Hospitalizations

• Previous Mental Health Treatment

• A Medical Profile

• Developmental History

• Educational/Vocational Status

• Current Living Situation


What to Include – Cont.

• Legal Status

• Substance Use Profile

• Resources and Strengths

• Mental Status Profile

• Diagnosis

• Professional Summary and Clinical Formulation

• Recommended Care and Initial Treatment Goals

• The Dated Signature of the assessor


What to Include – Cont.

For more information on assessments, see the provider training titled “Assessment Basics” posted to the Magellan of Virginia

web site under “For Providers,” 2017 Trainings.


Risk Assessments


12

Risk Assessment

• A comprehensive mental health risk assessment should be completed for all members seeking services

• Document that a risk assessment has been conducted, even if no risk was found

• Providers should assess for:

• Suicidal Ideation (plan, mean, intent, previous attempt, etc.) both past and current

• Homicidal Ideation (plan, mean, intent) both past and current

• Delusions

• Hallucinations (auditory, command, visual, tactile)

• Self harming behavior

• Run away behavior

• Extreme aggression, violent behavior, and assaultive behavior with or without a weapon


Safety Planning

• A safety plan must be created if a member discloses current risk behavior

• A safety plan should be in place for all members who have a history of risk behavior listed on the previous slide

• Safety plans should be based on the individual’s needs and should be unique to each member

• Plans may include the following information: • 24 hours Crisis Support contact number and person/agency

• Support people that can help assist with crisis (i.e. family member, friends, etc.)

• Behaviors identified by member as escalating behaviors

• Coping strategies for member and family

• How to communicate with the member when it is noted that behaviors are escalating

• A member identified treatment provider if emergency services are required


Safety Planning

• The Department of Behavioral Health and Developmental Services requires a safety plan as part of the ISP for all services licensed through them

• 12VAC35-105-665 states "The comprehensive ISP shall be based on the individual's needs, strengths, abilities, personal preferences, goals, and natural supports identified in the assessment. The ISP shall include: …..6. A safety plan that addresses identified risks to the individual or to others, including a fall risk plan; 7. A crisis or relapse plan, if applicable;…"

• Best practice is for all mental health providers to include safety planning for at risk members regardless of licensing requirements

• By incorporating safety planning during the intake process it ensures that the plan is created early and readily available to the member as part of their intake packet


Fall Risk Assessment

• A fall risk assessment is conducted to determine whether the individual has any physical conditions or other impairments that put her or him at risk for falling.

• A fall risk may include:

• Ambulatory difficulty

• Medications that cause dizziness

• Poor vision

• Previous falls

• A lack of assistive devices such as hand rails

• Improper use of assistive devices

• All children aged 10 years or younger should be assessed for fall risks based on age specific norms


Member Rights and Directives


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Member Rights

• At intake members must be informed of their rights

• For all services licensed by the Department of Behavioral Health and Developmental Services (DBHDS) members must be informed of their Human Rights under 12VAC35-115-20

• Member must be assured:

• Protection to exercise his/her legal, civil, and human rights related to the receipt of services;

• Respect for basic human dignity; and

• Services that are provided consistent with sound therapeutic practice.


Member Rights

• Best practice is to obtain informed consent from the member prior to

engaging in services

• Informed consent generally includes:

• An explanation of treatment/services

• An explanation of what is expected of the member during treatment/services

• Assurance that treatment/services can be terminated at any time without fear of retaliation

• An explanation of 3rd party payer information, i.e. what you are reporting to the insurance company

• Assurance that member information will be kept confidential unless express written permission is given, with the exception of suspected abuse, neglect, exploitation, or threats to seriously harm self or others


Provider Choice

• Federal code § 42 CFR 431.51 requires Medicaid members be able to obtain services from any Medicaid provider that is qualified to provide the service and willing to furnish services to that member.

• Provider choice is reiterated in 12VAC30-10-490 of the state legislative administrate code

• Best practice is to document that members are made aware of their provider choice and are choosing you as a provider


Advance Directives

• An advance directive is a legal tool that you can help members create

• Allows members to plan their care before an event occurs in case they are not able to make decisions for themselves

• Can be either for physical health, mental health, or both

• Advance directives for physical health focus on having a designated person to make decisions for the member in case they become incapacitated.

• Physical health advance directives allow members to express their desire for end of life decisions such as the use of life support and organ donation


Advance Directives

Mental health advance directives are a way for members to retain autonomy during a crisis and may include:

• Medications that work best for them

• Medications they do not want to receive

• Names of facilities or healthcare professionals they want involved in treatment

• People who can take care of bills or children should a crisis arise

• Who the member would like to make decisions for them during a mental health emergency

All members should be offered the opportunity to create an advance directive. If the individual chooses not to create any advance directives, providers should document that they offered to assist the member with this and that the member declined.


Access to a Primary Care Provider


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Primary Care Physician (PCP)

• Explore with member or guardian if they have a PCP

• The member or provider can contact Magellan or the member's MCO to obtain a list of PCPs in their area if the member does not have one

• Document when a member does not have a PCP or declines signing the release of information

• Share information with PCP at intake, discharge, and other significant points during treatment

• After obtaining consent to exchange information, ALWAYS inform the PCP of receipt of Mental Health services and request medical record

• Discuss with members the importance of the PCP being aware of services in case certain medications may be contraindicated or certain physical health conditions may be increasing mental health symptoms


Consent to Exchange Information


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Consent to Exchange Information

Providers should obtain a consent to exchange information for all parties with whom they may need to coordinate treatment/services.

Releases to exchange information should be obtained for:

• Other mental health providers (past and current)

• The School

• Primary Care Provider

• Other Medical Providers/Specialists

• Other significant persons

‒ Emergency contacts

‒ Probation officers

‒ Social workers


Resources

A copy of an Intake Checklist is available at www.MagellanofVirginia.comunder “For Providers” in the Behavioral/Medical Care Coordination Toolkit.

The Intake Checklist can be printed for use to guide Intakes and ensure all areas are covered.


http://www.magellanofvirginia.com/

http://magellanofvirginia.com/for-providers-va/behavioralmedical-care-coordination-toolkit.aspx

Resources

• Please review the Community Mental Health Rehabilitation Manual Chapter 4 for specifics on Service-Specific Provider Intake assessments: https://www.virginiamedicaid.dmas.virginia.gov/wps/portal/ProviderManual

• The Department of Behavioral Health and Developmental Services Chapter 105 Rules and Regulations for Licensing Providers: http://www.dbhds.virginia.gov/library

• Magellan Documentation Standards for Behavioral Health Treatment Records checklist: http://www.magellanofvirginia.com/media/1467807/07-2016_treatment_record_review_flyer_-_magellan_documentation_standards_tx_record_v1.pdf

• Advance Directive Resources: • Virginia Advance Directives:

http://www.virginiaadvancedirectives.org/home.html

• Mental Health America of Virginia: http://mhav.org/advance-directives/virginia-advance-healthcare-directive-resource-center/


https://www.ecm.virginiamedicaid.dmas.virginia.gov/WorkplaceXT/getContent?impersonate=true&id=%7b302C355B-0000-C01B-9CD2-AF4F09A718E4%7d&vsId=%7bCDA3CAF4-BDBD-4BA5-A6E0-B48DF3DF2A96%7d&objectType=document&objectStoreName=VAPRODOS1

http://www.dbhds.virginia.gov/library/developmental services/chapter 105 2013.pdf

http://www.magellanofvirginia.com/media/1467807/07-2016_treatment_record_review_flyer_-_magellan_documentation_standards_tx_record_v1.pdf

http://www.virginiaadvancedirectives.org/home.html

http://mhav.org/advance-directives/virginia-advance-healthcare-directive-resource-center/

Legal disclaimers

Confidentiality Statement for Educational Presentations

May 201730

By receipt of this presentation, each recipient agrees that the information contained herein will be kept confidential and that the information will not be photocopied, reproduced, or distributed to or disclosed to others at any time without the prior written consent of Magellan Health, Inc.

The information contained in this presentation is intended for educational purposes only and is not intended to define a standard of care or exclusive course of treatment, nor be a substitute for treatment.

Completing an Intake

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completing a comprehensive intake · • can be either for physical health, mental health, or both...

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