1. File Review Learning Lab Experience Matters! Valerie Cherry, PhD, Lead Mental Health Specialist Helena Mackenzie, PhD, Region V Mental Health Specialist Facilitator: Melissa Cusey, RN, Nurse Specialist

2. Learning Lab Groups of six individuals each (ideally with a CMHC in each group) Groups of six individuals each (ideally with a CMHC in each group) Each group has: Each group has: Leader: directs action for session Leader: directs action for session Recorder: writes for the group Recorder: writes for the group Reporter: shares the group’s work/reports out Reporter: shares the group’s work/reports out Help each other learn the process and practice! Help each other learn the process and practice!

3. Identify one challenge you have with the file review process. List one personal objective for this lab.

4. Objectives Describe the requirements and processes of the file review team, direct threat and health care needs assessments. Understand your role in the file review, direct threat and health care needs assessments. Complete thorough file reviews with clear documented summaries. Gain confidence through writing appropriate direct threat and health care needs assessments with peers.

5. Changes With New PRH Chapter One… What is the same? What has changed?

6. Essential Admission Requirements (EARS) Prior to conditional enrollment, OA assesses eligibility using EARS: Prior to conditional enrollment, OA assesses eligibility using EARS: Criterion I: Program Suitability (Education and training needs) Criterion I: Program Suitability (Education and training needs) Criterion J: Group Participation & Understanding Rules (participate successfully in group situation) Criterion J: Group Participation & Understanding Rules (participate successfully in group situation) Criterion K: Interference with Other Students’ Participation Criterion K: Interference with Other Students’ Participation (only EARS impacting center recommendations listed)

7. Once Eligible… ETA 6-53 & health documentation reviewed to determine whether JC can meet applicant health needs ETA 6-53 & health documentation reviewed to determine whether JC can meet applicant health needs If indicated, Health and Wellness staff review file, noting areas of potential concern (File Review Summary) If indicated, Health and Wellness staff review file, noting areas of potential concern (File Review Summary) FRT, including relevant health and wellness staff, interviews applicant and considers whether JC appropriate FRT, including relevant health and wellness staff, interviews applicant and considers whether JC appropriate How does the File Review Team determine if JC is an appropriate setting?

8. Additional Steps… If applicant has disability, the RAC also interviews applicant and identifies accommodations, with input from applicant If applicant has disability, the RAC also interviews applicant and identifies accommodations, with input from applicant FRT re-reviews file to see if concerns are ameliorated with identified accommodations FRT re-reviews file to see if concerns are ameliorated with identified accommodations File is forwarded to Center Director, who completes “reasonableness” determination (if indicated) and forwards file to Region File is forwarded to Center Director, who completes “reasonableness” determination (if indicated) and forwards file to Region

9. Recommendation for Denial at Center Level: Two Primary Reasons to Recommend Denial: Two Primary Reasons to Recommend Denial: Concern applicant is at significant risk of harming self or others Concern applicant is at significant risk of harming self or others Complete Direct Threat Assessment Complete Direct Threat Assessment Believe JC can not meet applicant’s health care needs Believe JC can not meet applicant’s health care needs Complete Health Care Needs Assessment Complete Health Care Needs Assessment Third (Rare) Reason to Recommend Denial: Third (Rare) Reason to Recommend Denial: New Information New Information Revisit specific EAR Revisit specific EAR

10. Health Care Needs Health care needs beyond JC basic health care responsibilities Red Flags: Frequent recent ER visits Newly diagnosed or uncontrolled health issue Symptoms/condition not well managed in similar environment as JC Require extensive resources/intervention

11. Direct Threat Significant risk of substantial harm Significant risk of substantial harm Threat is imminent : current specific behaviors, symptoms indicating instability Threat is imminent : current specific behaviors, symptoms indicating instability Burden is on JC to prove direct threat exists Burden is on JC to prove direct threat exists With disability, must consider whether accommodations decrease threat to acceptable level With disability, must consider whether accommodations decrease threat to acceptable level

12. Proposed Appendix 610 Health Care Needs Assessment A health care needs assessment should be completed whenever Job Corps believes that the health care needs of an applicant are beyond what the Job Corps’ Health and Wellness program can provide as defined as basic health care in PRH Exhibit 6-4: Job Corps Basic Health Care Responsibilities. A health care needs assessment should be completed whenever Job Corps believes that the health care needs of an applicant are beyond what the Job Corps’ Health and Wellness program can provide as defined as basic health care in PRH Exhibit 6-4: Job Corps Basic Health Care Responsibilities. This typically will occur after the applicant has received conditional assignment to a Job Corps center and has completed the 6-53 Health Questionnaire. This typically will occur after the applicant has received conditional assignment to a Job Corps center and has completed the 6-53 Health Questionnaire. Applicant has health care needs beyond basic health services as defined in PRH 6 Exhibit 6-4. Applicant has health care needs beyond basic health services as defined in PRH 6 Exhibit 6-4. Barriers to meeting health care needs cannot be eliminated or reduced by reasonable accommodation or modification. Barriers to meeting health care needs cannot be eliminated or reduced by reasonable accommodation or modification. 12

13. Indicators for a Health Care Needs Assessment? Two or more ER visits or one or more hospitalizations for medical, mental health, oral health, and/or substance abuse reasons. New diagnosis or recurrence of medical, mental health, extensive untreated oral health, and/or substance abuse condition that would require frequent medication adjustments, significant health resources and/or substantial change to the training day. Failure to follow previous treatment recommendations by licensed health providers that has adversely affected the applicant’s health, behavior, and/or adaptive functioning, and now requires significant health care management.

14. Indicators for a Health Care Needs Assessment? Applicant has followed treatment recommendations by licensed health providers with no improvement in applicant’s health, behavior, and/or adaptive functioning which continue to place applicant in need of significant health care management. Applicant’s condition or behavior has not been successfully managed in a similar academic, work, or group environment in the past year. Applicant is in treatment for a condition that is not in the scope of Job Corps Basic Health Care Responsibilities (e.g., orthodontic braces for malocclusion).

15. Health Care Barriers Frequency and length of treatment Severe medication side effects Hourly monitoring required Medical needs requiring specialized treatment Therapeutic milieu required Complex full mouth reconstruction or rehabilitation Complex behavior management system beyond Job Corps current system Out-of-state insurance impacting access to required and necessary health care Daily assistance with daily living skills [Other (specify)]

16. Review Process Health Care Needs Assessment The review should, at a minimum, be comprised of the following elements: The review should, at a minimum, be comprised of the following elements: A review of specific condition(s) identified on ETA 6-53, or self-disclosed by applicant. A review of specific condition(s) identified on ETA 6-53, or self-disclosed by applicant. Review of health documentation in the file. Review of health documentation in the file. Request additional recent health information, to determine applicant needs, if appropriate and medically necessary. Collaborate with OA counselor. Request additional recent health information, to determine applicant needs, if appropriate and medically necessary. Collaborate with OA counselor. Documented communication with treating provider, if possible and required if there are conflicting recommendations between the center health consultant and the treating provider. Documented communication with treating provider, if possible and required if there are conflicting recommendations between the center health consultant and the treating provider. 16

17. Review Process Health Care Needs Assessment Interview with applicant, and parent/guardian if a minor, either face to face, videoconferencing, or via telephone. If unable to contact applicant, all attempts need to be clearly documented including collaboration with OA counselor. Interview with applicant, and parent/guardian if a minor, either face to face, videoconferencing, or via telephone. If unable to contact applicant, all attempts need to be clearly documented including collaboration with OA counselor. If condition rises to a level of a disability then refer to the reasonable accommodation committee (RAC) for consideration of accommodations and/or modifications for discussion with applicant. See Appendix 605 for definition of a disability. If condition rises to a level of a disability then refer to the reasonable accommodation committee (RAC) for consideration of accommodations and/or modifications for discussion with applicant. See Appendix 605 for definition of a disability. Consider if accommodations and/or modifications would remove the barriers to enrollment and make condition manageable at Job Corps as defined by basic health services in PRH Exhibit 6-4. Consider if accommodations and/or modifications would remove the barriers to enrollment and make condition manageable at Job Corps as defined by basic health services in PRH Exhibit 6-4. 17

18. Decision Tree Health Care Needs Assessment Health care needs manageable at Job Corps as defined by basic health care services in PRH Exhibit 6-4, but may require community support services to be in place on entry due to special care needs (e.g., on-going community mental health treatment, specialized provider, etc.) to ensure continuity of care. Community support services available near center. Health care needs manageable at Job Corps as defined by basic health care services in PRH Exhibit 6-4, but may require community support services to be in place on entry due to special care needs (e.g., on-going community mental health treatment, specialized provider, etc.) to ensure continuity of care. Community support services available near center. Community support not available near requested center Community support not available near requested center Documentation of efforts to arrange for less frequent treatment in home state and to secure community support near requested center should be included in the file (i.e., name of organizations/facilities and specific individual contacted). Documentation of efforts to arrange for less frequent treatment in home state and to secure community support near requested center should be included in the file (i.e., name of organizations/facilities and specific individual contacted). File is forwarded to Regional Office for final determination File is forwarded to Regional Office for final determination 18

19. Decision Tree Health Care Needs Assessment Health care needs exceed basic health care as defined in PRH Exhibit 6-4. Health care needs exceed basic health care as defined in PRH Exhibit 6-4.. Applicant has health condition with current symptoms at a level that will interfere with successful participation in the program at this time. Deny entry and refer to other appropriate program/provider. Files forwarded to the Regional Office Files forwarded to the Regional Office 19

20. Decision Tree Health Care Needs Assessment Accommodations or Modifications Accommodations or Modifications If the individual is a person with a disability, the center’s reasonable accommodation committee (RAC) must convene and consider and discuss with applicant accommodations and/or modifications that the individual may need. Once the accommodations and/or modifications have been identified, the qualified licensed professional who conducted the original assessment must review the previous findings giving consideration to the identified accommodations to determine whether or not the accommodations and/or modifications can remove the barriers to enrollment due to health care needs. If the individual is a person with a disability, the center’s reasonable accommodation committee (RAC) must convene and consider and discuss with applicant accommodations and/or modifications that the individual may need. Once the accommodations and/or modifications have been identified, the qualified licensed professional who conducted the original assessment must review the previous findings giving consideration to the identified accommodations to determine whether or not the accommodations and/or modifications can remove the barriers to enrollment due to health care needs. 20

21. Decision Tree Health Care Needs Assessment Center Director Reasonableness Determination Center Director Reasonableness Determination If the individual is a person with a disability and accommodations or modifications that could remove the barriers to enrollment due to health care needs have been listed by the center’s reasonable accommodation committee (RAC), the Center Director is responsible for making a determination as to whether such accommodations or modifications would be “reasonable” or pose an undue hardship and if so, she/he will then recommend denial of the accommodation to the Regional Office. If the individual is a person with a disability and accommodations or modifications that could remove the barriers to enrollment due to health care needs have been listed by the center’s reasonable accommodation committee (RAC), the Center Director is responsible for making a determination as to whether such accommodations or modifications would be “reasonable” or pose an undue hardship and if so, she/he will then recommend denial of the accommodation to the Regional Office. 21

22. Health Care Needs(HCN) Large Group Practice I During the center file review process you receive the following: During the center file review process you receive the following: In the confidential health envelope, the 6-53 indicates an applicant who has received mental health treatment in the past and diagnosis of bipolar. There is a summary from group home that indicates applicant was terminated 3 months ago due to not following rules and engaging in arguments and fights with members in the group home. CCMP indicates applicant is noncompliant with medication and prognosis is poor without medication. Indicates applicant can attend Job Corps with weekly counseling and weekly psychiatric follow-up. Applicant has state funded insurance and is applying to center out of state. In the confidential health envelope, the 6-53 indicates an applicant who has received mental health treatment in the past and diagnosis of bipolar. There is a summary from group home that indicates applicant was terminated 3 months ago due to not following rules and engaging in arguments and fights with members in the group home. CCMP indicates applicant is noncompliant with medication and prognosis is poor without medication. Indicates applicant can attend Job Corps with weekly counseling and weekly psychiatric follow-up. Applicant has state funded insurance and is applying to center out of state.

23. 1. HCN: What Factors Triggered Review of the File For a HCN Assessment? Failure to follow previous treatment recommendations by licensed health providers that has adversely affected the applicant’s health, behavior, and/or adaptive functioning, and now requires significant health care management. Applicant’s condition or behavior has not been successfully managed in a similar academic, work, or group environment in the past year.

24. 2. What is applicant’s history and present functioning to support statement of HCN? File Review ETA 6-53 (Health Questionnaire)- Indicates this 17 year old applicant has a diagnosis of bipolar and is receiving weekly mental health and medication management. Applicant also checked “lost control of your anger, or feared losing control of your anger, to the point of hurting yourself or someone else?” ETA 6-53 (Health Questionnaire)- Indicates this 17 year old applicant has a diagnosis of bipolar and is receiving weekly mental health and medication management. Applicant also checked “lost control of your anger, or feared losing control of your anger, to the point of hurting yourself or someone else?” Applicant File Review Summary ( Brief summary of relevant information from medical records, IEP, school records, etc.) - Three months ago was terminated from group home due to unpredictable behavior resulting in verbal altercations with staff and 2 fights with group members. Mental health assessment two months described as having a “serious” level of impairment and needs to “improve ability to cope with stressors to decrease mood swings and aggressive behaviors.” Specific symptoms within the last three months include: uncontrolled cycling behavior, poor relationships with others, difficulty sleeping, decreased motivation, and refusal to comply with “authority figures. Applicant File Review Summary ( Brief summary of relevant information from medical records, IEP, school records, etc.) - Three months ago was terminated from group home due to unpredictable behavior resulting in verbal altercations with staff and 2 fights with group members. Mental health assessment two months described as having a “serious” level of impairment and needs to “improve ability to cope with stressors to decrease mood swings and aggressive behaviors.” Specific symptoms within the last three months include: uncontrolled cycling behavior, poor relationships with others, difficulty sleeping, decreased motivation, and refusal to comply with “authority figures.

25. Health Care Needs (HCN) Large Group Practice I File Review (continued): CCMP Provider Form (Recommend JC?): Yes-The treating therapist indicated that applicant could likely participate in JC, as long as he was able to continue receiving weekly mental health treatment, medication management and additional support on center as needed. Because this recommendation appeared somewhat inconsistent with information in the applicant’s file and interview, a brief follow up call was made to the therapist on October 10 th. During that call, the applicant’s therapist expressed concern that applicant would have difficulty living in the dormitory as he becomes highly stressed and has “meltdowns” in social situations. Therapist also indicated that applicant is non-compliant with medications and there has been an increase in mood swings Therapist indicated applicant must receive on-going weekly treatment at a minimum in therapeutic milieu. CCMP Provider Form (Recommend JC?): Yes-The treating therapist indicated that applicant could likely participate in JC, as long as he was able to continue receiving weekly mental health treatment, medication management and additional support on center as needed. Because this recommendation appeared somewhat inconsistent with information in the applicant’s file and interview, a brief follow up call was made to the therapist on October 10 th. During that call, the applicant’s therapist expressed concern that applicant would have difficulty living in the dormitory as he becomes highly stressed and has “meltdowns” in social situations. Therapist also indicated that applicant is non-compliant with medications and there has been an increase in mood swings Therapist indicated applicant must receive on-going weekly treatment at a minimum in therapeutic milieu.

26. Health Care Needs (HCN) Large Group Practice I File Review (continued): Applicant Interview Summary (Including clinical impression of applicant, e.g., mental status, behavioral observations, etc.) — The file review team, including the CMHC interviewed the applicant by telephone (he lives in another state and was unable to travel to center). The applicant acknowledged ongoing difficulty with emotional dysregulation and outbursts, but felt that he would be much happier “away from home.” Applicant currently reports feeling depressed, social withdrawal, and a lack of motivation. According to applicant he was doing better when he was on meds, but discontinued because he doesn’t like taking medicines. He seemed anxious during the phone call and became easily irritated when asked questions about specific mental health symptoms (particularly related to the cycling behavior); however, he answered all questions. Applicant Interview Summary (Including clinical impression of applicant, e.g., mental status, behavioral observations, etc.) — The file review team, including the CMHC interviewed the applicant by telephone (he lives in another state and was unable to travel to center). The applicant acknowledged ongoing difficulty with emotional dysregulation and outbursts, but felt that he would be much happier “away from home.” Applicant currently reports feeling depressed, social withdrawal, and a lack of motivation. According to applicant he was doing better when he was on meds, but discontinued because he doesn’t like taking medicines. He seemed anxious during the phone call and became easily irritated when asked questions about specific mental health symptoms (particularly related to the cycling behavior); however, he answered all questions.

27. 3. HCN: What are the Health Care Management Needs that are Barriers to Enrollment? Frequency and length of treatment Severe medication side effects Hourly monitoring required Medical needs requiring specialized treatment Therapeutic milieu required Complex full mouth reconstruction/rehabilitation Complex behavior management system beyond Job Corps current system Out of state insurance impacting access to required and necessary health care Daily assistance with daily living skills Other (specify)

28. 4. HCN: Does the Applicant Have Health Care Needs Beyond What the Job Corps’ Health and Wellness Program Can Provide? Applicant has health condition with current symptoms at a level that will interfere with successful participation in the program at this time. Deny entry and refer to other appropriate program/provider File is forwarded to Regional Office for final determination.

29. 5. HCN: If Student has Disability, RAC Must List Any Accommodations or Modifications Discussed with the Applicant That Could Remove or Reduce the Barriers to Enrollment 1.Adjust schedule to allow him to attend therapy and psychiatry appointments off center, if available in the community 2.Set breaks during the day and encouraged to touch base with designated supports during those times if needed 3. Provided with room in smaller dormitory After review of assessment considering the accommodations/modifications listed above, the barriers to enrollment can be eliminated or sufficiently reduced to allow for the applicant’s health care needs to be managed at JC XAfter review of assessment considering the accommodations/modifications listed above, the barriers to enrollment cannot be eliminated or sufficiently reduced to allow for the applicant’s health care needs to be managed at JC

30. Accommodations Modifications that will help student participate in program (not treat impairment) Accommodations: Accommodations: Distraction-free space Distraction-free space Modified schedule Modified schedule Frequent breaks Frequent breaks Peer buddy/tutor Peer buddy/tutor Positive behavior support Positive behavior support Visual supports Visual supports Single room/smaller dorm Single room/smaller dorm Case Management ( not accommodations ) Brief, periodic check-ins with CMHC Medication appointment Stress reduction group Participation in social skills group Attend off-center therapy

31. 6. HCN: Center Director Only If center recommends denial due to being unable to meet accommodations, CD must complete this final section ? Are accommodations reasonable or do they pose undue hardship on center ?

32. Direct Threat 1.What Factors Triggered a Review of Individual’s File for Direct Threat?

33. Direct Threat 2. What is the Nature/Severity of Potential Harm 1.What kind of harm is posed by the individual’s medical condition or disability? 2.What is the seriousness of the potential harm? (e.g., death, serious injury, minor emotional distress)

34. Direct Threat 3.What is the duration of the risk (e.g., how long will risk last)? 4.What is the likelihood that the potential harm will occur (e.g., high, moderate, low)? 5.What is the imminence of the potential harm (e.g., how soon likely to occur)?

35. Direct Threat 6.Based on factors above, does the named individual have a medical condition or disability that poses a significant risk of substantial harm to the safety of him/herself or of others if s/he participated, or continues to participate, in JC? In my professional judgment, the individual’s participation poses a direct threat In my professional judgment, the individual’s participation does not pose a direct threat

36. Direct Threat 7.List below any accommodations or modifications that could either eliminate the risk or reduce it to an acceptable level (** see next slide for examples) 1. 1. 2. 2. 3. 3. After review of the factors considering the accommodations/modifications listed above, the threat can be eliminated or reduced to a level below DT After a review of the factors considering the accommodations/modification listed above, the threat cannot be eliminated or reduced to a level below DT

37. Accommodations Modifications that will help student participate in program ( not treat impairment) Accommodations: Accommodations: Distraction-free space Distraction-free space Modified schedule Modified schedule Frequent breaks Frequent breaks Peer buddy/tutor Peer buddy/tutor Positive behavior support Positive behavior support Visual supports Visual supports Single room/smaller dorm Single room/smaller dorm Schedule adjustments (leave class early; time out to attend off-center appt) Schedule adjustments (leave class early; time out to attend off-center appt) Case Management ( not accommodations) Brief, periodic check-ins with CMHC Meet with MD for medication management Educate student about stress reduction Encourage participation in social skills group Attend off-center therapy

38. Direct Threat Center Director Only 8.If accommodations or modifications are listed in #7 above, you are responsible for making a determination as to whether such accommodations or modifications would be “reasonable” or pose an undue hardship. Document your determination on the space provided. Attach additional sheet or information if necessary.

39. PRACTICE! PRACTICE! Learning Lab Group Breakout

40. Learning Lab Practice Groups of six individuals each Groups of six individuals each Identify (quickly): Identify (quickly): Leader: directs action for session Leader: directs action for session Recorder : writes for the group Recorder : writes for the group Reporter : shares the group’s work/reports out Reporter : shares the group’s work/reports out

41. Direct Threat or Health Care Needs Assessment? **Quickly review two files at your table and determine which you think is most appropriate for DT and which for HCN? (5 minutes) **Check your decision with a group next to you (discuss if disagree)

42. Direct Threat Versus Health Care Needs? Direct Threat: Direct Threat: Imminence: Immediate safety concern Imminence: Immediate safety concern Suicidal behavior Suicidal behavior Homicidal behavior Homicidal behavior Impaired judgment Impaired judgment Paranoid thinking Paranoid thinking Threat of assault Threat of assault Health Care Needs May have safety issues related to health needs, but threat is not imminent Mood swings Impulsive behavior Poor diabetes control

43. Complete Health Care Needs Assessment As a group, work together to review data in file As a group, work together to review data in file Jot down medical and other information relevant to direct threat concern (two points from each source, e.g., 6-53, File Review Summary, CCMP, etc.). Jot down medical and other information relevant to direct threat concern (two points from each source, e.g., 6-53, File Review Summary, CCMP, etc.). Complete Health Care Needs Assessment as group Complete Health Care Needs Assessment as group Objective: teach each other (each of you will have a unique perspective regarding how to approach task) Objective: teach each other (each of you will have a unique perspective regarding how to approach task) Complete process in approximately 15 minutes! Complete process in approximately 15 minutes!

44. Complete Direct Threat Assessment As a group, work together to review data in file As a group, work together to review data in file Jot down medical and other information relevant to direct threat concern (two points from each source, e.g.. 6-53, File Review Summary, CCMP, etc.). Jot down medical and other information relevant to direct threat concern (two points from each source, e.g.. 6-53, File Review Summary, CCMP, etc.). Complete Direct Threat Assessment as group Complete Direct Threat Assessment as group Objective: teach each other (each of you will have a unique perspective regarding how to approach task) Objective: teach each other (each of you will have a unique perspective regarding how to approach task) Complete process in approximately 15 minutes! Complete process in approximately 15 minutes!

45. Large Group Report Out Reporter from each group will share a section from one of your assessments (e.g., nature and severity of potential harm, accommodations from DT, history/present functioning from HCN, etc.). Reporter from each group will share a section from one of your assessments (e.g., nature and severity of potential harm, accommodations from DT, history/present functioning from HCN, etc.). Large group will provide brief feedback on section shared, for instance: Are accommodations clear? (and not case management) Are important pieces of medical information included in HCN? Is enough documentation provided to uphold recommendation for denial?

46. Process Feedback: Confidence Ruler How confident do you feel in your understanding of the file review process and your ability to complete (with input from relevant FRT members) Direct Threat and Health Care Needs Assessment?

47. On your notecard: Identify one thing you want to do in the next month to increase your confidence in this process… Take your card with you!

48. Feedback Thank you for participating! Please complete your feedback form before you go.