Using Medicaid to Support Working Age Adults with Serious Mental Illnesses in the Community: A Handbook. APPENDIX B: Georgia Rehabilitative Services State Plan Amendment

01/24/2005

Georgia Medicaid State Plan Amendment:
Community Mental Health Rehabilitative Services (excluding EPSDT services)
(Effective: July 1, 2001)

13.d.1 -Community Mental Health Rehabilitative Services

"The covered Community Mental Health Rehabilitative Services will be available to all Medicaid eligibles with mental illness and substance abuse disorders and who are medically determined to need rehabilitative services. These services must be recommended by a physician or other practitioner of the healing arts within the scope of his/her practice under state law and furnished by or under the direction of a physician, or other practitioners operating within the scope the of applicable state law, to promote the maximum reduction of symptoms and/or restoration of a recipient to his/her best possible functional level."

The services are defined as follows:

Diagnostic/Functional Assessment. Individuals access this service when it has been determined through an initial screening that the person has mental health or substance abuse needs. The Diagnostic/Functional Assessment is required within the initial 45 days of service with ongoing assessments/services provided as needed. This process includes an initial face-to-face screening, additional face-to-face contacts with the consumer and collateral contacts with family members and other treatment providers to determine the consumer's problems and strengths, to develop a differential diagnosis, to identify the disability (ies), to determine the functional level, to determine natural supports and to develop or review an individualized service plan. This service includes developing outcomes, developing social and medical histories, identifying a consumer's symptoms, strengths and needs, conducting a comprehensive clinical evaluation and developing an individualized services plan. Information gathered during the Diagnostic/functional Assessment is used by the physician or the licensed practitioner within the scope of his/her practice to authorize or recommend rehabilitative services. The Diagnostic/Functional Assessment is used to provide and direct rehabilitative services for individuals in need of mental health and/or substance abuse services. Provider qualifications to provide these services are ensured by provider compliance with requirements and standards of the national accreditation Joint Commission on Accreditation for Healthcare Organizations (JCAHO), Commission on Accreditation for Rehabilitation Facilities (CARF), Council on Accreditation of Services for Children and Families, Inc. (COA), Council on Quality Leadership (CQL), and/or State certification. Providers are required to meet all applicable licensure and certification requirements, hold a current license and adhere to scope of practice definitions of licensure boards.

Clinic-Based Crisis Management. This service provides a face-to-face assessment and intervention to individuals in an active state of crisis. Services must be provided in a clinical setting. An immediate response is initiated and a thorough assessment of risk, mental status, and medical stability is conducted. Interventions are initiated to de-escalate the crisis. Intervention consists of rapid response to evaluate and screen the presenting situation, assistance in immediate crisis resolution and ultimately ensuring the Consumer's transition to alternate services at the appropriate level. Crisis management services are available 24 hours a day, 7 days a week. Provider qualifications to provide these services are ensured by provider compliance with requirements and standards of the national accreditation Joint Commission on Accreditation for Healthcare Organizations (JCAHO), Commission on Accreditation for Rehabilitation Facilities (CARF), Council on Accreditation of Services for on Quality Children and Families, Inc. (COA), Council Leadership (CQL), and/or State certification. Providers are required to meet all applicable licensure and certification requirements, hold a current license and adhere to scope of practice definitions of licensure boards.

Out-of-Clinic Crisis Management. This service provides assessment to individuals in an active state of crisis and can occur in a variety of settings including the consumer's home, local emergency departments, or other community settings. Immediate response is provided to conduct a thorough assessment of risk, mental status, and medical stability, and immediate crisis resolution and de-escalation if necessary. The presenting crisis situation is such that it is medically necessary to deliver the services in the consumer's home or natural environment setting in that the consumer does not have the resources, or state of mind to present at the clinic for crisis services. Each out-of-clinic crisis provider is required to offer face-to-face crisis management services 24 hours a day, 7 days a week. Provider qualifications to provide these services are ensured by provider compliance with requirements and standards of the national accreditation Joint Commission on Accreditation for Healthcare Organizations (JCAHO), Commission on Accreditation for Rehabilitation Facilities (CARF), Council on Accreditation of Services for Children and Families, Inc. (COA), Council on Quality Leadership (CQL),and/or State certification. Providers are required to meet all applicable licensure and certification requirements, hold a current license and adhere to scope of practice definitions of licensure boards.

Crisis Residential Services. This is a structured residential alternative or diversions from psychiatric inpatient hospitalization or inpatient detoxification. Crisis Residential Services are for individuals who are experiencing a period of acute stress that significantly impairs the capacity to cope with normal life circumstances for whom clinic or out-of-clinic services are not effective. The program provides psychiatric and/or substance abuse stabilization services that address the psychiatric, psychological, and behavioral health needs of the individuals. Specific services are: psychiatric evaluation, crisis stabilization and intervention, substance abuse detoxification, medication management and monitoring, individual, group and/or family training and counseling. A physician or a person under the supervision of physician, practicing within the scope of state law, provides crisis residential services. Services must be provided in a facility licensed as an emergency receiving and evaluating facility; however, not in an inpatient hospital or freestanding institute for mental disease (IMD). Services are provided in a facility that is less than 16 beds. This intervention is short-term, with the a length of stay not to exceed 72 hours except in individual circumstances where symptoms continue to Supersedes require this services. The need for additional services will be determined on an individual basis. Provider qualifications to provide these services are ensured by provider compliance with requirements and standards of the national accreditation Joint Commission on Accreditation for Healthcare Organizations (JCAHO), Commission on Accreditation for Rehabilitation Facilities (CARF), Council on Accreditation of Services for Children and Families, Inc. (COA), Council on Quality Leadership (CQL), and State certification. Providers are required to meet all applicable licensure and certification requirements, hold a current license and adhere to scope of practice definitions of licensure boards.

Individual Outpatient Services. Individual outpatient services provide face-to-face counseling services for symptom/behavior management of mental health problems and substance abuse treatment. Services are directed toward developing, restoring or enhancing interpersonal and adaptive behaviors and daily living skills. Provider qualifications to provide these services are ensured by provider compliance with requirements and standards of the national accreditation Joint Commission on Accreditation for Healthcare Organizations (JCAHO), Commission on Accreditation for Rehabilitation Facilities (CARF), Council on Accreditation of Services for Children and Families, Inc. (COA), Council on Quality Leadership (CQL), and/or State certification. This service maybe offered in a clinic setting or in the community. Providers are required to meet all applicable licensure and certification requirements, hold a current license and adhere to scope of practice definitions of licensure boards.

Family Outpatient Services. Family Outpatient services provide face-to-face counseling services to the eligible individual and their families for symptom/behavior management of mental health problems and substance abuse treatment. Services are directed toward the restoration and enhancement of the interpersonal skills of the individual within the family unit Services are directed towards the identified individual. Provider qualifications to provide these services are ensured by provider compliance with requirements and standards of the national accreditation Joint Commission on Accreditation for Healthcare Organizations (JCAHO), Commission on Accreditation for Rehabilitation Facilities (CARF), Council on Accreditation of Services for Children and Families, Inc. (COA), Council on Quality Leadership (CQL), and/or State certification. This service may be offered in a clinic setting or in the community. Providers are required to meet all applicable licensure and certification requirements, hold a current license and adhere to scope of practice definitions of licensure boards.

Group Outpatient Services. Group Outpatient services provide for symptom/behavior management; counseling; development, restoration or enhancement of adaptive behaviors and skills; and enhance mentor maintenance of daily living skills. Services are provided to individuals in a group setting. Services may include assisting individuals in the group with enhancing or developing symptom/behavior management skills, may provide knowledge regarding mental health and substance abuse disorders and prescribed medication (including adherence to medication regimen); may provide specific problem solving skills and coping mechanisms; may provide knowledge of adaptive behaviors and skills; and may provide assistance with interpersonal skills, or community resources and support system access. Provider qualifications to provide these services are ensured by provider compliance with requirements and standards of the national accreditation Joint Commission on Accreditation for Healthcare Organizations (JCAHO), Commission on Accreditation for Rehabilitation Facilities (CARF), Council on Accreditation of Services for Children and Families, Inc. (COA), Council on Quality Leadership (CQL), and/or State certification. This service maybe offered in a clinic setting or in the community. Providers are required to meet all applicable licensure and certification requirements, hold a current license and adhere to scope of practice definitions of licensure boards.

Medication Administration. Medication Administration is the giving or administration of an oral or injectable medication. Medication administration includes the assessment of the consumer's physical and behavioral status and a determination to continue the medication or refer the consumer to the physician. A physician or licensed nurse (working within the scope of his/her practice) can administer medication. Provider qualifications to provide these services are ensured by provider compliance with requirements and standards of the national accreditation Joint Commission on Accreditation for Healthcare Organizations (JCAHO), Commission on Accreditation for Rehabilitation Facilities (CARF), Council on Accreditation of Services for Children and Families, Inc. (COA), Council on Quality Leadership (CQL), and/or State certification. This service maybe offered in a clinic setting or in the community. Providers are required to meet all applicable licensure and certification requirements, hold a current license and adhere to scope of practice definitions of licensure boards.

Ambulatory Detoxification. This service is the medical management of the physical process of withdrawal from alcohol or other drugs in an outpatient setting. The services focus on the rapid physical stabilization of the consumer and entry into the appropriate level of care of treatment based upon the ASAM (American Society of Addiction Medication) guidelines placement criteria. The severity of the individual's symptoms, level of supports needed, and the physician's authorization for the service will determine the outpatient setting, as well as the amount of nursing and physician supervision necessary during the withdrawal process. The individual may or may not require medication; 24-hour nursing services are not required. However, there is a contingency plan for "after hours" concerns/emergencies. Provider qualifications to provide these services are ensured by provider compliance with requirements and standards of the national accreditation Joint Commission on Accreditation for Healthcare Organizations (JCAHO), Commission on Accreditation for Rehabilitation Facilities (CARF), Council on Accreditation of Services for Children and Families, Inc. (COA), Council on Quality Leadership (CQL), and/or State certification. Providers are required to meet all applicable licensure and certification requirements, hold a current license and adhere to scope of practice definitions of licensure boards.

Physician Assessment. A physician's assessment is the provision of specialized medical and/or psychiatric services that will result in improved levels of functioning or maintaining existing levels of functioning. The Physician Assessment provides a more comprehensive assessment of the medical psychiatric treatment needs of the individual. The information provided by the Diagnostic/Functional Assessment is used by the physician as an integral part of the assessment process, which supports diagnostic and treatment decisions. A Physician Assessment will be completed by a medical doctor. The Physician Assessment is performed by providers qualified to perform this function as determined through national accreditation Joint Commission on Accreditation for Healthcare Organizations (JCAHO), Commission on Accreditation for Rehabilitation Facilities (CAW), Council on Accreditation of Services for Children and Families, Inc. (COA), Council on Quality Leadership (CQL), and/or State certification. Providers are required to meet all applicable licensure and certification requirements, hold a current license and adhere to scope of practice definitions of licensure boards.

Nursing Assessment and Care. Nursing Assessment and Care is the face-to-face contact with a consumer to monitor, evaluate, assess, and/or carry out physicians' orders regarding the physical and/or psychological problems of a consumer. It includes providing special nursing assessments to observe, monitor and care for physical, nutritional and psychological problems or crises manifested in the course of the consumers treatment; to assess consumers on medication to determine the need to continue medication and/or for a physician referral; to consult with the consumer's family and/or significant other about medical and nutritional issues; medication education of the consumer and family and training for self administration of medication. The nurse's observations are reported to the physician and assist in overall medication management. Provider qualifications to provide these services are ensured by provider compliance with requirements and standards of the national accreditation Joint Commission on Accreditation for Healthcare Organizations (JCAHO), Commission on Accreditation for Rehabilitation Facilities (CARF), Council on Accreditation of Services for Children and Families, Inc. (COA), Council on Quality Leadership (CQL), and/or State certification. This service maybe offered in a clinic setting or in the community. Providers are required to meet all applicable licensure and certification requirements, hold a current license and adhere to scope of practice definitions of licensure boards.

Psychiatric Intensive Day Treatment. Intensive Day Treatment provides for the stabilization of psychiatric impairments with time limited, intensive, clinical service by a multi-disciplinary team in a clinic or facility-based setting. This service includes medication administration. Candidates for these services have adequate natural/community support systems and do have behavioral health issues, which are imminently dangerous. This level of care for each consumer should include services available at least 20 hours per week and must be ordered by the physician. The maximum allowed to bill in one day is 5 hours and does not include any residential, room or board supports. Weekend services may be necessary to meet the needs of consumers requiring crisis stabilization or other services. Services include physician and nursing services available on a daily basis. Mandatory services include medical services, family contact, group counseling, nursing services, medical management and continuing care planning. Available services include family counseling, individual counseling, and education/training as it pertains to the alleviation of identified behavioral health problems. Provider qualifications to provide these services are ensured by provider compliance with requirements and standards of the national accreditation Joint Commission on Accreditation for Healthcare Organizations (JCAHO), Commission on Accreditation for Rehabilitation Facilities (CARF), Council on Accreditation of Services for Children and Families, Inc. (COA), Council on Quality Leadership (CQL), and/or State certification. Providers are required to meet all applicable licensure and certification requirements, hold a current license and adhere to scope of practice definitions of licensure boards.

Psychosocial Rehabilitation. A therapeutic rehabilitative social skill building service for individuals to gain the necessary social and communication skills necessary to allow them to remain in or return to naturally occurring community programs. Services include: skill building activities that focus on the development of problem-solving techniques, social skills and medication management, and recreational activities that improve self-esteem. These services are offered in group settings. This service is provided as a step-down from intensive day treatment. Services must be provided in a clinic or other facility-based setting. Provider qualifications to provide these services are ensured by provider compliance with requirements and standards of the national accreditation Joint Commission on Accreditation for Healthcare Organizations (JCAHO), Commission on Accreditation for Rehabilitation Facilities (CARF), Council on Accreditation of Services for Children and Families, Inc. (COA), Council on Quality Leadership (CQL), and/or State certification. Providers are required to meet all applicable licensure and certification requirements, hold a current license and adhere to scope of practice definitions of licensure boards.

Psychosocial Day Support. This service focuses on training designed to assist the consumer in the acquisition, retention or improvement of self-help, socialization and adaptive skills, which takes place in a facility-based environment with adequate staff support. These services provide less costly step-down service as an alternative to psychosocial rehabilitation. Individuals appropriate for these services do not meet the admission criteria for intensive day treatment or psychosocial rehabilitation. Providing a lower level of intensity this structured program assists consumers to attain his/her maximum functional level and is coordinated with other services on the Individualized Service Plan (ISP).Day Supports maybe used to reinforce skills or knowledge in more intensive level services. Provider qualifications to provide these services are ensured by provider compliance with requirements and standards of the national accreditation Joint Commission on Accreditation for Healthcare Organizations (JCAHO), Council on Accreditation for Rehabilitation Facilities (CARF), Council on Accreditation of Services for Children and Families, Inc. (COA), Council on Quality Leadership (CQL), State certification. Providers are required to meet all applicable licensure and certification requirements, hold a current license and adhere to scope of practice definitions of licensure boards.

Substance Abuse Intensive Outpatient Services. This service is a time limited treatment service for persons who require structure and support to achieve and sustain recovery. The following types of services are included in the intensive outpatient program: didactic presentations on addiction and recovery, individual and group counseling; family counseling (as it relates to the consumer's substance abuse treatment issue), regular urine drug screening; and community and social support system strategies. Services must be provided in a clinical setting. Family counseling as provided within these services must be consistent with requirements outlined in Family Outpatient services. Provider qualifications to provide these services are ensured by provider compliance with requirements and standards of the national accreditation Joint Commission on Accreditation for Healthcare Organizations (JCAHO), Commission on Accreditation for Rehabilitation Facilities (CARF), Council on Accreditation of Services for Children and Families, Inc. (COA), Council on Quality Leadership (CQL), and/or State certification. Providers are required to meet all applicable licensure and certification requirements, hold a current license and adhere to scope of practice definitions of licensure boards.

Residential Rehabilitative Supports. Residential Rehabilitative Supports are rehabilitative services for the treatment of mental health or substance abuse problem specifically provided to individuals in a 24 hour supervised residential setting. The specific treatment services that are covered include: daily living skills training (personal hygiene skills, performance of household tasks, utilization of public transportation), behavior management training and intervention, counseling or therapy. Services are delivered to individuals according to their specific needs. Individual and group activities and programming shall consist of services to restore and develop skills in functional areas which interfere with consumer's ability to live in the community, to live independently, or regain or maintain competitive employment, to develop or maintain social relationships or to independently participate in social, interpersonal or community activities. Rehabilitative services will be provided in a certified or licensed residential setting. This service does not include inpatient hospital or care in an Institute for Mental Diseases. Services are provided in a facility that is less than 16 beds. Provider qualifications to provide these services are ensured by provider compliance with requirements and standards of the national accreditation Joint Commission on Accreditation for Healthcare Organizations (JCAHO), Commission on Accreditation for Rehabilitation Facilities (CARF), Council on Accreditation of Services for Children and Families, Inc. (COA), Council on Quality Leadership (CQL), and/or State certification. Providers are required to meet all applicable licensure and certification requirements, hold a current license and adhere to scope of practice definitions of licensure boards.

Assertive Community Treatment (ACT). ACT is an intensive mental health service for consumers discharged from a hospital after multiple or extended stays, or who are difficult to engage in treatment. Intensive, integrated rehabilitative, crisis, treatment and community support services provided by an interdisciplinary staff team and available 24-hours/ seven days a week and be ordered by the physician. Services offered by the ACT team must be documented in an Individual Service Plan (ISP) and must include (in addition to those provided by other systems): medication administration and monitoring; self medication; crisis assessment and intervention; symptom assessment, management and individual supportive therapy; substance abuse training and counseling; psychosocial rehabilitation and skill development; personal, social and interpersonal skill training; consultation, and psycho-educational support for individuals and their families. This service is community-based. The team must include a psychiatrist and/or registered nurse, a Mental Health Professional (MHP) (SAP), or Substance Abuse Professional and/or a Peer/family Support Specialists. Provider qualifications to provide these services are ensured by provider compliance with requirements and standards of the national accreditation Joint Commission on Accreditation for Healthcare Organizations (JCAHO), Commission on Accreditation for Rehabilitation Facilities (CARF), Council on Accreditation of Services for Children and Families, Inc. (COA), Council on Quality Leadership (CQL), and/or State certification. Providers are required to meet all applicable licensure and certification requirements, hold to a current license and adhere to scope of practice definitions of licensure boards.

Community Support Services. Community support services consist of mental health and substance abuse rehabilitative, services and supports necessary to assist the person in achieving rehabilitative and recovery goals. This service is often a step-down from Assertive Community Treatment, Intensive Family Intervention and Residential Rehabilitative Supports. The service activities of Community Support consist of a variety of interventions: identification and intervention to address barriers that impede the development of skills necessary for independent functioning in the community; participation in the development of the consumer's Individualized Service Plan (ISP), and one-on-one interventions with the consumer to develop interpersonal and community coping skills, including adaptation to home, school and work environments; symptom monitoring and self management of symptoms. The focus of the interventions include, minimizing the negative effects of psychiatric symptoms which interfere with the consumer's daily living, financial management, and personal development; developing strategies and supportive interventions for avoiding out-of-home placements for adults and children; assisting consumers to increase social support skills that ameliorate life stresses resulting from the consumer's disability and coordinating rehabilitative services in the ISP. An individual or a team can provide community Support Services. Provider qualifications to provide these services are ensured by provider compliance with requirements and standards of the national accreditation Joint Commission on Accreditation for Healthcare Organizations (JCAHO), Commission on Accreditation for Rehabilitation Facilities (CARF), Council on Accreditation of Services for Children and Families, Inc. (COA), Council on Quality Leadership (CQL), and/or State certification. Providers are required to meet all applicable licensure and certification requirements, hold a current license and adhere to scope of practice definitions of licensure boards.

Peer Support. This service provides structured, scheduled activities that promote socialization, recovery, self-advocacy, development of natural supports, and maintenance of community living skills, under the direct supervision of a mental health professional. Consumers actively participate in decision-making and program operation. Services are directed toward achievement of the specific goals defined by the individual and specified in the Individual Service Plan (ISP), and provided under the direct supervision of a Mental Health Professional. The interpersonal interactions and activities within the program are directed, supervised, guided and facilitated by the Mental Health Professional (MHP) in such a way to create the therapeutic community or milieu effect required to achieve individual treatment goals within a controlled environment. This concept is similar to the manner in group therapy sessions in which the staff leader or therapeutic community setting utilizes the interactions of the group members to achieve the desired individual therapy goals. Provider qualifications to provide these services are ensured by provider compliance with requirements and standards of the national accreditation Joint Commission on Accreditation for Healthcare Organizations (JCAHO), Commission on Accreditation for Rehabilitation Facilities (CARF), Council on Accreditation of Services for Children and Families, Inc. (COA), Council on Quality Leadership (CQL), and/or State certification. This service maybe offered in a clinic setting or in the community. Providers are required to meet all applicable licensure and certification requirements, hold a current license and adhere to scope of practice definitions of licensure boards.

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