WBHN
Service
Specifications
Outpatient Services
Mental Health
Program Specifications,
Credentials
Section A
Effective: 10/1/2011
Revised: 10/1/2012
1.0
Purpose
Outpatient services are designed to reduce maladaptive behaviors, maximize behavioral selfcontrol, or restore normalized psychological functioning, reality orientation, remotivation, and
emotional adjustment, thus enabling improved functioning and more appropriate interpersonal
and social relationships. Outpatient therapy services may be provided to individual beneficiaries,
to groups of beneficiaries or to a beneficiary and members of his/her family. A diversity of
providers will be maintained to meet the needs of a diverse population.
2.0
Services:
A.
Additional WBHN expectations of Outpatient Therapy services include:
1.
Time-limited outpatient therapy and counseling activities for youth or adults.
2.
Utilization of many models and diverse approaches including evidenced based
and promising practices delivered in a wide variety of settings and based upon
individual needs, including but not limited to, Trauma Focused Cognitive
Behavioral Therapy (TF-CBT), Motivational Enhancement Therapy/Cognitive
Behavioral Therapy (MET/CBT), Parent Management Training of Oregon (PMTO),
Integrated Dual Disorder Treatment for Co-occurring Disorders (IDDT/COD),
Dialectical Behavior Therapy (DBT), and Multi-Systemic Therapy (MST).
B.
Department of Human Services (DHS) and WBHN Collaboration Requirements for Youth:
1.
Work in collaboration with DHS to serve youth in foster care and/or who have
Abuse I and II risk categories.
2.
Services must be trauma-focused and reportable to both KCMHSAS and DHS.
3.
Ensure coordination of care with primary physician and other providers including
but not limited to: medical, dental, psychiatric, medication monitoring,
psychological consultation as needed, community resources, transportation,
vocational training, school and legal systems.
4.
Must submit monthly progress reports to DHS which include:
a. Record of counseling sessions, kept and unkept appointments
b. Progress toward treatment goals and objectives
c. Treatment plan updates reflecting any changes
d. Client’s cooperation with treatment
e. Diagnosis
f. Recommendations
g. Complete discharge paperwork including:
i. Diagnosis at termination
ii. Treatment summary
iii. Objectives and progress on objectives
iv. Total number of sessions (kept and unkept)
v. Cooperation in treatment
vi. Reason for closure.
Service components include:
1
WBHN
Service
Specifications
Outpatient Services
Mental Health
Program Specifications,
Credentials
Section A
Effective: 10/1/2011
Revised: 10/1/2012
C.
General Service Components for Outpatient Services (Mental Health)
1.
Initial and on-going Bio-psychosocial assessments of individual and family service
needs.
a. A Brief Screen, which is a face to face behavioral health screening to
determine the need for mental health and/or substance abuse services.
b. An Assessment, which is an individual, face-to-face assessment at the
licensed provider level for the purpose of identifying functional and service
needs to formulate the basis for the Individualized Plan of Services (IPOS)
and/or Treatment Plan.
2.
Development of an Individualized Treatment Plan or IPOS based on
comprehensive bio-psychosocial assessments, diagnostic impressions and
consumer characteristics such as age, gender, culture and development. Plans
will include problem formulation, treatment goals and measurable treatment
objectives. Plans must be reviewed and up-dated.
3.
Person Centered/Family Centered Planning which addresses all beneficiary needs
in the pertinent domains. Plans must be reviewed and up-dated at least annually
or as often as the individual requests.
4.
Dual diagnosis service capability provided in a welcoming environment.
5.
Service Coordination
a. Coordination with the primary care physician and/or physician who prescribes
psychiatric medication.
b. Coordination of services for medical, psychiatric, medication monitoring, and
psychological consultation as needed.
c. Coordination with and/or referral to community resources for "wraparound"
support services such as child care, transportation, vocational training, school
systems, legal systems, and Department of Human Services.
6.
Early Intervention services which are any planned intervention that may assist a
person to abstain from alcohol and/or drug use.
7.
Outpatient Services (individual, family and group psychotherapy)
a. Individual therapy, which is 1:1 face-to-face counseling services with the
beneficiary.
b. Family therapy, which is face-to-face counseling with the beneficiary and
his/her significant other and/or traditional or non-traditional family members.
c. Group therapy, which is face-to-face counseling with three or more
beneficiaries
and
can
include
didactic
lectures,
therapeutic
interventions/counseling, and other group-related activities.
8.
Ensuring access to language interpreter, translation services and hearing
interpreter services.
9.
Discharge planning beginning at the on-set of treatment which includes
coordination of after care and referral for on-going supports/services.
3.0
Access, Authorization and Discharge:
A.
Eligibility
Individuals served must have a diagnosis of an Axis I condition or developmental
disability, and/or Axis I diagnosis reflected in the DSM IV.
2
WBHN
Outpatient Services
Service
Specifications
B.
Mental Health
Program Specifications,
Credentials
Section A
Effective: 10/1/2011
Revised: 10/1/2012
1.
Mental Health Services (including co-occurring services)
The focus of treatment must be related to the Axis I diagnosis or a concomitant
Axis II diagnosis, and;
a. Psychiatric signs and symptoms resulting in minimum to moderate disruption
in self-care, relationship, employment or school, and other areas of life.
b. Suicidal ideation, non-accidental behavior or suicidal gestures that have
potential to cause serious injury or threaten life.
c. Inappropriate behavior towards others that is threatening or sexually
aggressive with potential for harm.
d. Adults receiving service must assume responsibility for their own treatment
and change.
2.
Outpatient Care services should be limited to individuals who will benefit from
treatment and have been determined to have the following:
a. Demonstrated readiness to change
b. Minimal or manageable medical conditions
c. Minimal or manageable withdrawal risks
d. Level of care suited to emotional, behavioral and cognitive conditions
e. Minimal or manageable relapse potential
f. Minimally to fully supportive recovery environment
Authorization
1.
Mental Health Services (Eligibility, Level of Care and Access Center Role)
Determination of eligibility and assignment of a level of care is done by the WBHN
Access. An integrated assessment tool(s) behavioral health issues is completed.
Individuals are provided with informed choice of provider upon determination of
level of care required. The WBHN Access staff will forward the initial diagnostic
impression, level of care determination and service authorization, including the
amount, scope and duration of service, to the provider chosen by the person along
with a release of information.
a. Initial Authorization.
A comprehensive bio-psychosocial assessment is completed which concludes
that the individual does not meet criteria to be served under the 20-outpatient
visit benefit of a Medicaid Mental Health Plan. Scope and duration of service
is determined consistent with clinical criteria for the diagnosis and treatment
modality to be employed, typically 4-20 sessions. On average, the Individual
should be seen for outpatient services at least two times a month.
b. Ongoing Authorization.
Services may be re-authorized based on extensive clinical justification of
continued progress or change in treatment modality.
of continued progress or change in treatment modality.
C.
Discharge
Individuals shall be discharged, and transitioned from outpatient services when:
1.
The individual no longer meets the severity of illness criteria and has demonstrated
the ability to meet all major role functions for a period of time sufficient to
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WBHN
Outpatient Services
Service
Specifications
Mental Health
Program Specifications,
Credentials
Section A
Effective: 10/1/2011
Revised: 10/1/2012
demonstrate clinical stability. If an individual requests transition to other service(s)
because they believe they have received maximum benefit, consideration for the
transition must be reviewed during the person-centered planning (PCP) process. If
clinical evidence supports the individual’s desire to transition, this evidence and the
transition plan must be detailed in a revised Individual Plan of Service developed
through the PCP process. The plan must identify what supports and services will be
made available.
2.
3.
4.
5.
6.
4.0
Engagement of the individual in outpatient services is not possible, and the
individual is unwilling to participate in treatment.
The individual has moved outside of the geographic area and contact continues
until services have been established in the new location.
Referral to a more intensive treatment modality is justified by assessment.
Individual no longer meets medical necessity criteria. Medical necessity criteria
can employ various methods to determine the amount, scope, duration of services,
including prior authorization for certain services, concurrent utilization reviews,
centralized assessment and referral, gate keeping arrangements, protocols and
guidelines.
Other factors influencing discharge:
a. The individual does not demonstrate capacity to benefit from outpatient services.
b. There is a significant change in the individual’s psychiatric illness, and the
individual would be more appropriately served by another treatment modality.
c. An individual is incarcerated in long term treatment or criminal justice facility.
Credentials:
Staff qualification requirements for MDCH and Medicaid services are noted in the documents
referenced in Section 5.0, References.
5.0
References:
Services and provider credentials must be consistent with the requirements of the following
documents as applicable:
Medicaid Provider Manual – Mental Health and Substance Abuse Services
 Section 3 Individual/Group Therapy
Southwest Michigan Affiliation (SMA) Policies
 Section 2.0 Provider Network Management
 Section 6 Customer Services
 Section 23 Grievance and Appeals
 Section 24 Rights of Recipients
 Section 25 Rights Complaints and Dispute Resolution
 Section 30 Utilization Management and Access
 Section 31 Clinical Practices
 Section 32 Intake and Assessment
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WBHN
Service
Specifications
Outpatient Services
Mental Health
Program Specifications,
Credentials



Section 33 Consumer Planning
Section 34 Transition, Discharge and Follow-up
Section 40 Services Coordination
 Section 42 Children and Adolescents
Children’s Administrative Rules
 Section 330.2125
PIHP- MHSP Provider Qualifications for Medicaid Services
5
Section A
Effective: 10/1/2011
Revised: 10/1/2012