1. Agency Introduction Detailed Session – Day 1

2.  Welcome & Introductions  Housekeeping  Objectives of the Training 2

3.  In 2014, the Legislature passed SB 6312 to integrate public funding for Mental Health and Substance Use Disorder treatment services  Counties could choose to convert their existing mental health Regional Support Networks to “Behavioral Health Organizations” [BHOs] 3

4.  BHOs will be responsible for managing public funding for Substance Use Disorder (SUD) services as well as Mental Health services  BHOs will officially begin on April 1  The State will provide “capitated” payments to the BHOs for all medically necessary SUD and MH services for Medicaid enrollees. 4

5.  BHOs will be responsible for setting all rates and will be “at risk” for paying for both outpatient and residential treatment costs.  BHOs are responsible to establish and fund treatment networks that provide all “medically necessary” services to Medicaid enrollees.  BHOs are to provide Crisis Services and treatment services within available resources to other low-income persons. 5

6.  In addition to Medicaid and State General Fund dollars, Substance Abuse Block Grant and CJTA dollars will also be allocated though BHO budgets  BHOs must develop budgets that combine all of these different funding streams but within the restrictions that apply to each 6

7. CURRENT – MENTAL HEALTHNEW – SUD AND INTEGRATED Crisis ServicesIntegrated Crisis Services Involuntary CommitmentCD “Involuntary Commitment” Evaluation & Treatment Facilities Acute Detox [Evergreen Recovery] Triage Centers – mental health Whatcom and Skagit Triage: sub-acute detox Psychiatric Hospitalization Psychiatric Residential Treatment SUD Residential Treatment

8. CURRENT – MENTAL HEALTHNEW – SUD AND INTEGRATED Outpatient ServicesSUD Individual and Group OP Intensive Outpatient ServicesSUD Intensive OP Medication ManagementMedication Assisted Treatment PACT Teams Children’s Wrap-Around - WISe SUD services for Pregnant and Parenting Women Jail TransitionUnfunded

9. A new “Interlocal Agreement” between the 5 North Sound counties has been signed which creates the North Sound BHO as a “Limited Liability Corporation”  Board of Directors  Advisory Board  County Coordinators  Planning Committee  Quality Management Oversight Committee  Other ad-hoc workgroups

10. Improving the Behavioral Health and Well-Being of Individuals and Families in Our Communities 10

11. BridgewaysCatholic Community Services Center for Human ServicesCompass Health Consumer Voices are BornEvergreen Recovery Centers Lake Whatcom CenterPhoenix Recovery Pioneer Human ServicesSea Mar Sunrise ServicesTherapeutic Health Services TelecareUnity Care NW Volunteers of America (VOA)

12.  Major component of public mental health services  Available to all individuals and families physically located in the North Sound region’s five counties, regardless of enrollment status with service providers, ability to pay, or funding source.

13.  Available on a 24 hour basis for those who are in a self-defined state of crisis ◦ A crisis is defined as a turning point in the course of anything decisive or critical; a time, a stage or an event of great danger or trouble, whose outcome decides whether possible bad consequences will follow 13

14.  Voluntary and involuntary crisis services are provided by Compass Health in Island, San Juan, Skagit and Whatcom Counties  Compass Health provides voluntary crisis services in Snohomish County  Snohomish County Human Services provides involuntary treatment services in Snohomish County 14

15.  Broad array of crisis services ◦ Telephone-based crisis assessment and support ◦ Outreach ◦ Crisis triage centers ◦ Involuntary treatment assessments 15

16.  Treat individual in crisis as a whole person  See crisis as self-defined  Offer easy and timely access to appropriate intervention and care  Stabilize in the least restrictive setting  Community-based  Actively involve and collaborate with family members and other natural supports 16

17.  Available to both adults and children  Available 24 hours a day, 365 days a year throughout the Region  Fully integrated and coordinated at both the local and regional level  Culturally competent and responsive 17

18.  Care Crisis Response Services (CCRS) ◦ Run by Volunteers of America ◦ Provides a 24-hour a day, 7 day a week, professionally staffed crisis line system for consumers (1-800-584-3578) ◦ Provides a 24-hour a day, 7 day a week, professionally staffed (Masters-level MHPs) triage line system for professionals (1-800-747-8654) 18

19.  CCRS Support & Referral Services ◦ Referrals ◦ Providing telephone consultation, intervention, and stabilization services for individuals and natural supports ◦ Scheduling crisis appointments ◦ Dispatch of CPIT and DMHPs ◦ Urgent contacts ◦ Follow up services 19

20.  CCRS Support & Referral Services (cont) ◦ Tracking the outcome of face-to-face crisis services ◦ Working closely with law enforcement ◦ Consulting with detoxification providers, licensed care facilities, hospitals and other community providers 20

21.  Outreach ◦ Face-to-face evaluation and/or intervention services (voluntary or involuntary) in community locations ◦ Accessed through the crisis line or triage line and performed by CPIT or DMHPs ◦ Expectation that outpatient clinicians work with enrolled individuals during business hours  Coordinates with Crisis Services when they need further assistance  VOA CCRS can assist with this coordination 21

22.  Crisis Prevention and Intervention Teams ◦ Available in Snohomish, Skagit and Whatcom counties ◦ For individuals and families not currently enrolled in Medicaid outpatient services ◦ Intended to crisis mental health situations  Situations where the level of stress has overwhelmed the individual’s ability to cope  Peers are part of the team  Skagit is piloting and integrated crisis outreach with CDPs ◦ Provides intervention to assess, engage, provide temporary support and make referrals to community resources 22

23.  Involuntary Investigations ◦ Designated Mental Health Professionals (DMHPs)  Assess for danger to self, others, property and/or grave disability  Can detain the individual for up to 72 hours ◦ Superior Court Judge  14 days  90 days (adults), 180 days (children) 23

24.  Crisis Stabilization/Triage Facilities ◦ Skagit, Snohomish, and Whatcom Counties ◦ Adults ◦ Provide short-term (up to 5 days) support who are in or at high risk of experiencing a mental health crisis ◦ Skagit and Whatcom programs provide sub-acute detoxification, Snohomish program provides (non- medical) sobering services ◦ Contact facility or CCRS Crisis/Triage Line to make referral 24

25.  Emergency Psychiatric Medication Evaluations ◦ Generally for non-enrolled individuals ◦ At risk for hospitalization per EMHC or DMHP ◦ Access through EMCH or DMHP  Urgent Contact: Timely access to face-to-face mental health evaluation/intervention services when needed, to prevent the individual’s situation from deteriorating to the point that Emergent care is necessary. These calls require a response by the NSMHA provider within 24 hours of the VOA CCRS Clinician’s notification.  Follow-up Services: Appointments offered when the caller does not require “Emergent” or “Urgent” intervention, but there is an indication that without prompt assessment/intervention further decompensation is likely. This appointment may be initiated at the request of the VOA CCRS Clinician, or by any other Clinician within the ICRS system. Follow-up services may also be offered to non- enrolled individuals needing Follow-up contact while awaiting transition into ongoing care. 25

26.  Collaboration between outpatient and crisis services essential  Crisis Management Tools ◦ Crisis Plans  Completed by consumer and clinician  VOA access ◦ Crisis Alerts  Current info for impending crisis  Expire in 10 days, may be renewed  VOA access 26

27.  Crisis Management Tools (continued) ◦ Advance Directives  Consumer’s declaration of instructions & preferences ◦ Court Orders  Conditions  Outpatient provider responsibilities 27

28.  Requests for Service ◦ VOA Centralized Access Line 800-693-7200  Monday – Friday 8 am – 5 pm ◦ Directly to BHA ◦ Policy 1503

29.  Intake Evaluation ◦ Access to Care Standards (ACS) ◦ Policy 1504  Authorization process ◦ Request authorization or denial ◦ North Sound BHO determination ◦ Policy 1505

30.  Reauthorization requests ◦ Individual wishes to remain in services beyond their initial authorization period and Continuing Stay Criteria are met ◦ Policy 1505

31.  Substance Use – ASAM ◦ American Society of Addiction Medicine  Mental Health - LOCUS & CALOCUS ◦ Level of Care Utilization System (LOCUS) and Child & Adolescent Level of Care Utilization System (CALOCUS) tools  LOC Guidelines ◦ Services and hours of service identified for each LOC ◦ http://nsmha.org/Policies/Sections/1500/1565.02. pdf http://nsmha.org/Policies/Sections/1500/1565.02. pdf  Policy 1565

32. 32 ALL provider sites must have at least one person trained in CANS Online, flexible training Used when making a referral to WISe for individuals <21 WISe provider enters data into BHAS Result sent to referring provider and added to clinical record

33.  Medically Necessary  Recovery Orientation  Culturally Competent ◦ Special Population Consultations ◦ Interpreters and Translators 33

34.  Modalities ◦ Routine Services  Individual Treatment Services, Group Services, Medication Management ◦ Intensive Services  WISe, IOP, PACT, IDDT, Residential ◦ Medicaid Personal Care 34

35. Wraparound with Intensive Services (WISe) Skagit, Snohomish, Whatcom Research/Evidence Based Early Period Screening, Diagnosis, & Treatment 35

36.  Intensive Outpatient Program for Adults (IOP) ◦ Treatment team ◦ Community-based services ◦ Available 24/7 ◦ Goals  Reinforcement of safety  Promotion of stability and independence in community  Restoration to higher level of functioning ◦ All Counties except San Juan ◦ Policy 1567 36

37.  Program of Assertive Community Treatment (PACT) ◦ Evidence-based ◦ Person-centered, recovery-oriented ◦ Support for community living, psychosocial rehabilitation ◦ Multi-disciplinary treatment team ◦ Community-based services ◦ Available 24/7 ◦ Programs in Skagit, Snohomish, Whatcom Counties ◦ Policy 1563 37

38.  Integrated Dual Disorder Treatment (IDDT) ◦ Evidence-based ◦ Focus on integration  Assessment, treatment plan, treatment ◦ Multi-disciplinary treatment team ◦ Available 24/7 ◦ 2 programs  Skagit and Snohomish 38

39.  Mental Health Services in a Residential Setting ◦ Provider at facility ◦ Therapeutic interventions beyond custodial care  Residential Facilities ◦ Snohomish, Compass Health  Aurora House (RTF), Greenhouse (RTF), Haven House (RTF) ◦ Whatcom, LWC (ALF) ◦ Assisted Living Facility (ALF) vs. Residential Treatment Facility (RTF)  Policy 1532 39

40.  Medicaid Personal Care (MPC) ◦ Policy #1576 ◦ Hands-on assistance with Activities of Daily Living (e.g., personal hygiene, dressing, meal prep, eating, med management, shopping) ◦ Two types  In-home care, provided at the individual’s residence  Adult Family Home (AFH) daily rate 40

41.  MPC (continued) ◦ Eligibility  Washington Apple Health (Medicaid)  In current outpatient services with North Sound BHO Behavioral Health Agency  Need for MPC services must be based upon a solely psychiatric disability, not a physical disability or substance use issue ◦ Determination Process  Home and Community Services (HCS) Assessment  North Sound BHO Review ◦ Agree or Disagree with payment 41

42.  15 minutes 42

43.  Routine Services ◦ Outpatient ◦ Intensive Outpatient ◦ Medication Assisted Treatment ◦ Opiate Substitution Treatment ◦ Withdrawal Management 43

44.  Routine Outpatient, ASAM 1 & 2.1, 12 months  Intensive Inpatient ASAM 3.5, 30 days  Long Term Residential ASAM 3.3, 60 days  Recovery House ASAM 3.1, 180 days  PPW Residential, ASAM 3.3 and 3.5, 180 days 44

45.  Assessment by community OP provider to determine need and LOC; secure bed date; secure residential authorization for that provider  With other BHO developing a contracting consortium to reduce number of contracts for providers and consistent data reporting needs.  Intent to retain existing system providers.  In process of bringing into provider network, to be completed this week. 45

46.  Coordinated Services ◦ Two or more providers delivering services to the same individual during an episode of care ◦ Facilitated by first agency contacting second agency directly ◦ Agreement about who has primary responsibility for care including crisis management ◦ All involved providers must maintain a complete record  Policy 1510

47.  Transfer of Services ◦ Individual changes providers ◦ Facilitated by first agency via VOA Access or contacting second agency directly for intake evaluation/assessment  Additional steps for programs with limited capacity ◦ Responsibility for care remains with first agency until transfer complete

48.  Out of Network Referrals ◦ Used in cases where a needed service is not available w/in current provider network ◦ Ensure provision of medically necessary services  Less restrictive alternatives  Subcontract arrangements ◦ Policy 1522

49.  Consumer right to second opinion ◦ Medical Necessity ◦ Reasonableness or necessity of recommended interventions ◦ Diagnosis or recovery plan ◦ Interventions not improving consumer’s condition  Rendered by clinician with credentials equal to or higher than clinician rendering initial opinion  Process ◦ Internal vs. External ◦ One second opinion, per issue, per year  Policy 1520 49

50. ACS SUD + ACS MH BHO Benefit ACS SUD + Non ACS MH BHO + Core Connections Benefits Health Care Authority Foster Care Team @1-800-562-3022 ext. 154801-800-562-3022 50

51.  Hospitals ◦ St. Joseph’s Hospital – Bellingham ◦ Skagit Care Center – Mount Vernon ◦ Swedish Edmonds – Edmonds ◦ Fairfax – Kirkland, Monroe and Everett ◦ Children’s – Seattle

52.  Freestanding Evaluation & Treatment Centers (E&Ts) ◦ Not hospitals ◦ Snohomish County – Mukilteo ◦ Skagit County-Sedro Woolley  Adults  Primarily Involuntary ◦ Kitsap - Bremerton  Adults and Youth (8-17) ◦ Two Rivers Landing (Youth)- Yakima ◦ Navos (Adults) - Seattle

53.  Authorization ◦ Volunteers of America (VOA) ◦ Determine medical necessity for voluntary hospitalizations  Designated Mental Health Professionals (DMHPs) determine medical necessity for involuntary ◦ Issue authorizations for voluntary and involuntary hospitalizations

54.  Requests for voluntary hospitalization ◦ Assessment of consumer by MHP within 24 hours of request ◦ Eligibility, Acuity, Expected Benefit ◦ Contact hospital to request placement ◦ Request for certification/authorization

55.  Outpatient Provider Responsibilities ◦ VOA will notify outpatient clinician of admission ◦ Contact hospital within 3 working days of admit ◦ Contact with consumer if stay is longer than 7 days ◦ Attempt medication consultation ◦ Outpatient follow-up appointment within 7 calendar days of discharge ◦ Follow-up psychiatric appointment within 7 business days of discharge ◦ Policy 1572

56.  Children’s Long-Term Inpatient Program (CLIP) ◦ Most restrictive level of care for children/youth ◦ Child Study & Treatment Center (CSTC), Navos (formerly McGraw), Pearl Street Center, Tamarack ◦ Referral Process  Western State Hospital ◦ Most restrictive level of care for adults ◦ Screening process 56

57. Q & A 57

58.  Clinical Guidelines ◦ http://nsmha.org/PDFs/Clinical_Guidelines/Clinical _Guidelines_Manual.pdf http://nsmha.org/PDFs/Clinical_Guidelines/Clinical _Guidelines_Manual.pdf  Forms ◦ http://nsmha.org/Forms/index.asp http://nsmha.org/Forms/index.asp  Policies ◦ http://nsmha.org/Policies/Complete_TOC.aspx http://nsmha.org/Policies/Complete_TOC.aspx  Regional Training Modules ◦ Relias – contact Mandy Iverson at North Sound BHO 58