Section 11: Behavioral Health Services Providers
Philosophy and Components of Service:
CCA’s person centered approach is an integral part of who we are as a leading health care organization. Senior Care Options (SCO) and One Care (OC) enrollees are the principal voices in the planning and management of their care. Interprofessional Care Teams (ICTs) compose our Members preferred professional support system, including CCA care partners, primary care providers, specialty providers, behavioral health providers, home- and community-based services providers, and Long-Term Services and Support (LTSS) coordinators. CCA identifies and engages enrollees in care management programs to enable them to overcome barriers that limit their ability to manage their own health and well-being. This is conducted in a manner consistent with each enrollee’s personal and cultural values, predicated on Recovery and Wellness principals and with the goal of helping Members reach their self-defined level of optimal functioning.
Commonwealth Care Alliance is committed to full integration of Behavioral Health Services that includes our members self-directed components of a care team members as noted above. We hold our providers to the highest standard of care and expect that contracted Behavioral Health (BH) providers will work closely with our ICTs including CCA teams, PCPs and LTSS support coordinators as well as any specialty BH or other provider. Our network of outpatient and diversionary services providers is built to ensure that each member has access to a provider within a fifteen (15) mile, thirty (30) minute radius of their zip code.
Providers may provide services utilizing telehealth and are responsible for ensuring telehealth services are HIPAA compliant and follow MassHealth guidelines for the use of telehealth to deliver covered services. Accordingly, a full continuum of Behavioral Health services is available to all Commonwealth Care Alliance Members. Behavioral Health services fall into the categories described below, all of which are covered by Commonwealth Care Alliance and some of which are subject to prior authorization requirements.
The provider complies with all provisions of the corresponding section in the service specific performance specifications for each level of care for which they are contracted.
Access, Care Planning and Documentation
- The Provider ensures that services are managed in a way that minimizes or eliminates waiting lists for services.
- Providers must ensure access to twenty-four (24) hour Emergency Service Programs for all Members.
- Providers should contact CCA’ s Provider Services at 866-420-9332 for assistance with claims, payment, appeals, member eligibility/member ID, inpatient admission notification, substance use service notification, BH prior authorization requests or clinical concerns regarding Members care.
- With consent, the Member and their guardian/caregiver, family members or other natural supports are active and integral participants throughout the service delivery process, including assessment, treatment planning, treatment services, discharge planning, and related meetings.
- Office visits must be available within the following timeframes to CCA Members for Behavioral Health Services other than emergency services, Emergency Service Programs or Urgent Care:
- Services described in the Inpatient or 24-Hour Diversionary Services Discharge Plan
- Non-24-Hour Diversionary Services within 2 calendar days of discharge
- Appointments to review and refill medications within 14 calendar days of discharge
- Other Outpatient Services within 7 calendar days of discharge
- All other Behavioral Health Services within 14 calendar days
- In addition to our contracted Network, CCA’s Behavioral Health Licensed Clinicians are available 24/7 on call. BH Clinicians are also available for in person home, office, or telehealth appointments within 48 hours of discharge and 48 hours for medication assessment and management.
- The provider makes best efforts to offer meetings, such as treatment planning meetings, and services and family therapy sessions, at times and locations convenient to the Member and the family’s schedule, including evening and weekend meeting times and the use of telemedicine.
- With consent, the Member’s CCA Individual Care Team (ICT), other behavioral health providers, state agency staff, and other supports are engaged in treatment and discharge planning meetings.
- The provider completes an initial written, comprehensive assessment for all Members entering any level of care, which is documented in the Member’s health record.
- The assessment includes, but is not limited to: history of presenting problem; chief complaints and symptoms; strengths; behavioral health, substance use, medical, developmental, family, and social history; linguistic and cultural background; mental status examination including assessment of suicide and violence risk; previous and current medications, and any allergies to medications; DSM-5 diagnosis and clinical formulation that are supported by the clinical data gathered, rationale for treatment, and treatment recommendations; name of the CCA Care Partner and other key providers.
- For Members, the initial outcome measurement is administered prior to or on the date of the comprehensive assessment completion to document that the clinical data was integrated into the initial assessment process. Information in the assessment may be gathered from the Member, family/guardian/caregiver, the referral source, past and current treaters, and/or other collateral contacts, with appropriate consent.
- When requested and/or as indicated by the members clinical presentation, the provider conducts and documents in the Member’s health record a substance use disorder assessment either directly or by linkage with a provider trained in substance use disorders.
- The provider completes a comprehensive and individualized initial treatment plan based on the assessment and developed with the Member and/or guardian/caregiver, and, with consent, family members, the CCA ICT, PCP, state agencies, recovery and peer support specialists or other involved providers and supports identified by the Member.
- The treatment plan is signed, dated, and documented in the Member’s health record and includes but is not limited to: objective and measurable goals, time frames, expected outcomes, the Member’s strengths, links to primary care especially for Members with active co-occurring medical conditions, a plan to involve a state agency case manager, when appropriate, and treatment recommendations consistent with the service plan of the relevant state agency, if involved.
- The time frames for the completion of the initial treatment plan are delineated in each of the service-specific performance specifications.
- The provider assigns a multi-disciplinary treatment team to each Member within the time frames delineated in each of the service- specific performance specifications. A multi-disciplinary treatment team meets to review the assessment and initial treatment plan and discharge plan within time frames delineated in each of the service- specific performance specifications.
- The treatment plan is implemented, reviewed, and revised throughout the course of treatment, based on the provider’s continual reassessment of the Member and with the Member’s participation.
- The Member’s progress in achieving the treatment goals is documented in progress notes and treatment plan updates in the Member’s health record.
- If the Member terminates treatment without notice, every effort is made to contact the Member to re-engage in treatment or to provide assistance to transfer the Member to another appropriate source of care prior to discharging the Member. Such activity is documented in the Member’s health record.
- The provider seeks informed consent from the Member in order to coordinate admissions, assessment, treatment/care planning, and discharge planning with the following collaterals, as appropriate to the level of care. The type and amount of information shared is appropriate to the purpose and the role of those to/from whom the information is being communicated/requested, including the following:
- Caregivers/family/significant others/natural supports;
- CCA’s ICT;
- Emergency Services and Community Crisis Stabilization (CCS);
- 24-hour levels of care, including psychiatric hospitals;
- State agency involved teams, including DMH, DPH, DDS, MCB, MCDHH, EOEA and/or DTA;
- Police departments and local court systems;
- Outpatient therapists, medications prescribers and all other community supports including Community Support Programs (CSPs), and substance use programs.
Discharge Planning and Documentation: The provider complies with all provisions of the corresponding section in the service-specific performance specifications for each level of care for which they are contracted.
- The provider ensures that staff who are responsible for discharge planning are knowledgeable about the continuum of behavioral health and medical services as well as other services and supports in the community, and discharge planning skills and strategies.
- Staff involved in discharge planning are expected to locate appropriate step-down and other aftercare services for CCA Members.
- Providers are expected to contact the CCA Care Team by calling CCA’s Provider Services at 866-420-9332 (option #4) for all discharge and aftercare planning, transportation support and other service needs.
- The provider identifies barriers to discharge planning and aftercare and develops strategies to assist the Member with arranging and utilizing aftercare services, making best efforts to ensure that the discharge plan (or other such document(s) that contain the required elements) is consistent with their benefit coverage.
- As appropriate, the provider assists the Member in scheduling a follow-up appointment for the Member with their PCP and the CCA ICT.
- With the Member’s consent, the provider, in collaboration with the Member, their family, and/or their supports, develops a written, individualized, person-centered, strengths-based discharge plan, prior to the Member’s discharge from any inpatient service or, if appropriate, any other behavioral health service, that is documented in the Member’s health record. Prior to the Member’s discharge, the provider provides the Member with a copy of the discharge plan (or other such document(s) that contain the required elements). The plan includes but is not limited to Identification of the Member’s Social Determinants of Health needs.
- The Provider is expected to reach out to the CCA Care Partner to notify CCA’s ICT of Member’s discharge plan and collaborate with coordinating aftercare.
- For Members discharged from inpatient mental health services and for other Members as clinically indicated, an updated crisis and/or safety prevention plan that follows the principles of recovery and resilience, a list of the services and supports that are recommended post-discharge, including identified providers, and other community resources available to deliver each recommended service;
- A list of prescribed medication, dosages, and potential side effects; and
- Treatment recommendations consistent with the service plan of the relevant state agency for Members who are state-agency involved.