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Page Posted: 5/2012

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Chapter 7: Community-based Services

B. Rehabilitation: Adult Rehabilitative Mental Health Services (ARMHS)

1. Scope

  • • Overview
  • • Characteristics
  • • Service Coordination
  • • Non-covered services
  • 2. Eligible Recipients

    3. Delivery

    4. Eligible Providers

    5. Documentation and Monitoring

    1. Scope

    This section describes the policies and procedures of Adult Rehabilitative Mental Health Services (ARMHS) which are funded by Medicaid and other Minnesota Health Care programs. ARMHS are available to adults who meet the eligibility requirements.

    Overview

    Adult Rehabilitative Mental Health Services (ARMHS) are a set of services that were developed to bring restorative, recovery-oriented interventions directly to individuals who have the capacity to benefit from them, whether in their homes or elsewhere in the community. This means that skills that have been lost or diminished due to the symptoms of mental illness can be acquired, practiced, and enhanced whenever and wherever they are needed.

    In the past, rehabilitative mental health services were provided by social service agencies and were not widely considered medical services. Over time, professionals in the mental health community became aware of their effectiveness and embraced services that emphasized recovery and the restoration of skills that were impaired or lost due to mental illness. As awareness in the medical community grew, these special services, or components of them, were seen to be both more humane and more cost-effective than institutionalization or hospitalization.

    Characteristics

    ARMHS includes four components: basic living and social skills, community intervention, medication education, and transitioning to community living.

    Basic living and social skills

    People need basic living skills and social skills in order to be independent. This component teaches many of these skills and supports individuals as they practice them. Examples include:

  • • Communicating opinions, thoughts and feelings, or key information with others
  • • Feeling confident in different social roles and settings
  • • Communicating about, or when in a stressful situation
  • • Discovering and using community resources to get needs met
  • • Getting outside help to deal with a difficult situation
  • • Preventing relapse
  • • Budgeting and shopping
  • • Developing a healthy lifestyle
  • • Learning to cook and eat a healthy diet
  • • Learning to get around the community
  • • Monitoring use and effectiveness of medications
  • • Managing the symptoms of mental illness
  • • Managing a household
  • • Finding and retaining a job
  • • Planning for employment
  • • Pursuing education
  • • Re-entering community living after treatment
  • Most of these skills are developed one-on-one, but some are taught in a group setting, provided that group learning is a benefit for each person in the group, and is specified in her or his treatment plan. (See “Group modality” later in this section.) Each person’s treatment plan specifies the skills that are needed, how they will be acquired and/or generalized to other similar situations, and in which mode (individual or group) they are to be provided. The plan must make it clear that the intervention is medically necessary.

    Community intervention

    Community intervention means a series of strategies aimed at reducing barriers to integration in the community, independent living, or securing community living when symptoms of the mental illness have become unmanageable. These strategies minimize the risk of a loss of community living which could result in the loss of a job, eviction, hospitalization, etc.

    Services would involve the ARMHS staff person, either with or without the individual present, to work with relatives, guardians, friends, employer, landlord, treatment provider(s), or other significant people in an effort to resolve a difficult situation. The identified resource person would be asked to make some change that would promote or stabilize the person’s independent functioning.

    A community intervention

  • • Must be aimed exclusively at the person’s treatment
  • • Must be provided on an individual basis-not in a group
  • • May be conducted in person, or by telephone
  • • Can be conducted without the individual being present if they cannot be present, or if the strategy could result in a more effective outcome without their presence
  • Community intervention services are not
  • • Routine communication among members of a treatment team, a routine staffing, or a care conference
  • • Telephone contacts that do not conform to the definition of this service or that are not properly documented
  • • Clinical supervision or routine service coordination activities with other professionals
  • • Developing a treatment plan
  • Medication education

    Medication education teaches individuals about mental illness and its symptoms. It also teaches people about the role of prescription medication and its effects, including side effects. Families and/or significant others may participate in medication education along with the client. Only a registered nurse, pharmacist, physician’s assistant, or physician may provide this training. Medication education can be provided either one on one or in a group within a preferred community, home, or office setting.

    Transitioning to community living

    Transitioning to community living services are provided to an individual who will be leaving a sub-acute level of care service, such as Assertive Community Treatment (ACT), a skilled nursing facility, an Intensive Residential Treatment Services (IRTS) program, or an acute care service such as a regional treatment center, or an inpatient hospital setting.

    These services provide a way for a rehabilitation services provider and the sub-acute or acute care provider to work with the person in a mutual manner. By working together, discharge planning can promote successful entry or re-entry into community living.

    While closely tied, transitioning services do not duplicate discharge planning services expected of the sub-acute or acute care provider, nor are they provided concurrently or in conjunction with other ARMHS services. An individual may receive these services only when a facility cannot provide them or is not responsible for providing them.

    Service Coordination

    ARMHS services can be the only mental health services that an individual may require, or as a compliment to other services a person may have. ARMHS services may be delivered by multiple ARMHS providers as deemed beneficial by the individual. To assure for service coordination, it is helpful that providers ask potential ARMHS participants what other services they have received or are currently receiving as a part of the admissions process.

    Some participants may also require additional services, whether concurrent with or independent of ARMHS. Such as, an intensive residential setting or a brief hospital stay. Coordination of care is imperative to assure continuity and consistency of care and treatment. ARMHS providers must be aware of limitations or additional requirements during concurrent or independent episodes of care among multiple providers. (Link rehab overview -authorization)

    Non-covered Services

    Many activities fall outside the scope of ARMHS services. These activities are generally paid as “other covered services,” or else they do not meet the level of medical necessity requirements or are not reimbursable as a health care service. Minnesota Statutes 256B.0623, subd.13, provides the following examples of services that cannot be billed under ARMHS:

  • • Transporting recipients
  • • Services provided and billed by providers who are not enrolled or certified to provide ARMHS
  • • ARMHS performed by volunteers
  • • Tasks the provider performs for the recipient, such as housekeeping, laundering, grocery shopping, moving the recipient’s household (sometimes called “do-for” services or activities)
  • • Time spent on-call and not delivering services
  • • An ARMHS service that is not medically necessary or is not documented as medically necessary
  • • Social or recreational activities that are not rehabilitative
  • • Case management services
  • • Outreach services to potential recipients
  • • ARMHS services that are provided to a recipient during a hospital, IMD, or residential treatment facility admission
  • • Room and board services
  • • Vocational services
  • 2. Eligible recipients

    A person who is eligible to receive ARMHS:

  • • Is age 18 or older
  • • Has received a recent diagnostic assessment by a qualified mental health professional that indicates ARMHS services are medically necessary;
  • • Has substantial disability and functional impairment in three or more areas, thus markedly reducing self-sufficiency; and
  • • Has the cognitive capacity to engage in and benefit from rehabilitative services techniques and methods.
  • Comprehensive diagnostic and functional assessments are required to determine eligibility, medical necessity, and appropriateness of rehabilitation services. It is also important to remember that the goal of this service is to regain or restore lost capabilities associated with the symptoms of the diagnosed mental disorder.

    For this service, the initial diagnostic assessment must be:

    (a) No more than 180 days old, beginning on the admission date of the current episode of care; or

    (b) Must be conducted within 30 days from the admission date; or

    (c) Be completed within 5 days of the second meeting following the date of admission.

    To establish medical necessity for ARMHS, the functional assessment must do two things:

    1) Identify the symptom(s) associated with the diagnosis; and

    2) Clearly describe how the mental illness is affecting functioning within a domain.

    A good functional assessment makes clear the links among functioning, the mental illness, and the environment

    The functional assessment must be completed within 30 days of the start date or admission date, and must be reviewed and updated at least once every 6 months. However, the narrative portion should be updated more often because the person’s abilities and functioning may change as a result of services received.

    3. Delivery

    Individual ARMHS services are usually provided in a person’s home, but they may be provided at the home of a relative or significant other. They may also be provided at a job site, psychosocial clubhouse, drop-in center, classroom, library, or at some other location in the person’s community. Confidentiality is especially important in settings outside the home.

    However, ARMHS services can not be provided in a regional treatment center, nursing facility, or acute care hospital unless a person is making the transition to community living in the immediate future and a discharge date has been determined.

    Group modality: As distinct from individual work, a group can help individuals by allowing for role-plays, modeling, and practicing skills with peers. Groups afford a safe place to practice new skills before applying them within their life and community. In order for a person to participate in an ARMHS group, the clinical supervisor must approve the use of this modality and document how a group learning environment is medically necessity. In doing so, the clinical supervisor approves the group over individual modality because the structure of a group supports the person’s ability to learn, practice, and generalize targeted skills more effectively.

    Each participant in the group has a rehabilitation goal and objective based on his or her service plan. The goal is linked to the group experience. In each session, a rehabilitative intervention is presented to improve a skill. Once learned, the skill is expected to be generalized throughout the participant’s life. The intervention is described in each participant’s progress note along with his or her response to the intervention and plans for the next session.

    To account for the different ways adults learn, rehabilitation-oriented groups use visual, auditory, and kinetic styles.

    ARMHS groups follow this typical pattern:

    1. Say: Instructor explains the skill set and how it is used in different roles or situations.

    2. Demonstrate: Instructor demonstrates how the skill is used.

    3. Practice: Members practice using the skill with the instructor.

    4. Demonstrate: Instructor repeats the demonstration.

    5. Demonstrate: Members demonstrate the skill with an instructor or peer.

    6. Score: Members evaluate each other’s use of the skill.

    7. Practice: Members practice with each other.

    8. Integration: Before the next group session, members determine how they can use the skill in natural settings.

    9. Summary: Instructor recaps (a) what was learned during the session, (b) how each member will practice or make use of the skill, and (c) the plan for the next session.

    Here are some strategies that can make ARMHS groups more effective:

  • • Arrive early to assure a welcoming environment.
  • • Come prepared to conduct a group learning experience. Set up the room in advance; have handouts, pens, or other materials ready.
  • • Connect group members to one another by asking each member’s purpose in participating:
  • • What goal(s) are you working on?
  • • How can this group help you meet your goal(s)?
  • • Make sure that role-plays clearly relate to members’ goals and life situations.
  • • Ask participants: Who can you practice this skill with today or tomorrow, and where? Ask them to write down the answers in a to-do list.
  • • At the beginning of the next session, ask each member to recount her or his practice, and to say whether it went well or not so well.
  • • Talk with ARMHS staff about how engaged the members are and how they are progressing. If progress is lacking, consult with the staff about ways to reinforce the use of new skills in an individual session.
  • 4. Eligible Providers

    ARMHS providers must be certified by DHS in accordance with Minnesota Statutes 256b.0623.

    Purpose and process of certification

    Certification ensures that agencies or provider entities (e.g., nonprofit or for-profit private providers, county entities, or tribal authorities) can provide the full array of ARMHS services, either directly or under contract.

    Through certification and recertification, each ARMHS provider documents and verifies the following:

  • • Direct-service providers are qualified and have access to the required training.
  • • Professional clinical supervision is available through the agency, either directly or under contract. (The clinical supervisor must be a mental health professional enrolled in MHCP and have a national provider identifier number (NPI))
  • • The provider entity is enrolled in MHCP and has a NPI, or for atypical providers, a “unique Minnesota provider identifier” (UMPI).
  • • Personnel files are maintained in accordance with Minnesota Statute 256b.0623.
  • • The ARMHS services billed are medically necessary.
  • • Documentation meets Medicaid standards for rehabilitative services.
  • • Each recipient has a case file that includes the following:
  • • A diagnostic assessment, functional assessment, and individual rehabilitation plan
  • • Documentation of current symptoms, history of mental illness, health/medical history, any current medications
  • • Signed release forms and emergency contacts
  • • Case records (progress notes) that document dates of service, place of service, signature of qualified person providing service, the nature of the service, and extent or units of service (in accordance with MA standards)
  • • Service-related contacts, whether direct or by telephone; contacts may include the client’s other providers or other resources and/or a facility where the client is currently receiving services
  • • A list of resources for coordinating services
  • • Any information written by the client that she or he wants to include in the file
  • The ARMHS Website contains a list of currently certified providers and their expiration dates.

    Unique provider requirements

    This section describes roles, responsibilities and requirements of individual providers.

    Providers of medication education

    Medication education must be provided by a physician, pharmacist, registered nurse or physician’s assistant.

    The ARMHS clinical supervisor

    The clinical supervisor is a licensed mental health professional in good standing who provides clinical supervision to mental health practitioners and mental health rehabilitation workers delivering ARMHS. Each ARMHS agency must have at least one mental health professional on staff to fulfill this role. The clinical supervisor may be a full-time or part-time employee of the agency or under contract with the agency.

    The responsibilities of the clinical supervisor include the following:

  • • Determining whether the potential client is eligible for ARMHS services
  • • Reviewing a client’s file at least every 6 months after the start of service
  • • Analyzing all assessment information to establish rehabilitative treatment priorities and to develop an individual rehabilitation service plan
  • • Updating individual rehabilitation service plans
  • • Delivering clinical supervision to all ARMHS staff at least once a month, either by meeting individually or in small groups, to provide information on various mental health diagnoses and/or discuss rehabilitative treatment topics of interest.
  • • If the treatment director is a mental health practitioner, meeting with him/her at least once a month to
  • • Fulfill the role of treatment director
  • • Review the needs of the ARMHS program
  • • Review the field supervision observations of mental health rehabilitation workers on staff
  • • Plan staff education trainings
  • • Examine and provide input into the agency’s development, program evaluation, and strategic quality improvement plans
  • • Note that monthly meetings with the treatment director must be documented.
  • • Being available for urgent consultation as required by a situation or by a client’s needs
  • The ARMHS treatment director

    Every ARMHS provider agency requires a treatment director. If not filled by the clinical supervisor, the treatment director may be a mental health professional or a mental health practitioner working under the clinical supervision of a mental health professional who is the clinical supervisor.

    The treatment director is responsible for:

  • • Conducting field observations in supervising mental health rehabilitation workers delivering ARMHS
  • • Reviewing progress notes of onsite visits to ensure they are accurate and consistent with the purpose of the visit and goals of the treatment plan
  • • Overseeing (a) records of observations, (b) charting evaluations, and (c) actions that correct the work of mental health practitioners and rehabilitation workers
  • • Approving and signing the field record of observations, located in the personnel file of the mental health rehabilitation worker
  • • Being available for consultation with mental health practitioners and mental health rehabilitation workers, either by phone or in person, or making sure that a mental health professional or mental health practitioner is available
  • • Determining that treatment is implemented correctly; overseeing changes in treatment strategies and revisions in treatment plans; conveying instructions and methods of treatment as appropriate
  • • Modeling service practices that (a) demonstrate respect for the client (e.g., including clients in planning and implementing the treatment plan, recognizing clients’ strengths) and (b) promote collaboration and coordination.
  • • Ensuring that mental health practitioners and mental health rehabilitation workers can communicate effectively with clients, their significant others, and other providers
  • An ARMHS treatment director who is a mental health practitioner must receive supervision at least once a month from the clinical supervisor. During this consultation, the clinical supervisor and treatment director:

  • • Identify and plan for the general needs of the population they serve
  • • Address the needs and effectiveness of the program
  • • Address personnel issues and needs, including training
  • • Plan, implement, and evaluate the quality improvement plans of the provider agency
  • The following organizational chart exhibits the provider structure within an ARMHS entity.

    DHS image

    5. Documentation and provider organization data reporting

    Documentation

    The rehabilitation intervention is the focus of service delivery. The rehabilitation service plan, which is based on the results of diagnostic and functional assessments, identifies the individual’s recovery vision, rehabilitation goals and objectives, as well as the specific interventions to be delivered.

    Note that an individual community support plan (as defined in Minnesota Statute 245.462, subd. 12) may serve as the treatment plan, provided the client has a mental health case manager to approve it. The plan must include all elements of the individual rehabilitation service plan. A description of rehabilitative interventions is given in the rehabilitation overview of this guide. For additional information on developing service plans for ARMHS, refer to Minnesota Statute 256b.0623.

    Progress notes are used to document the services that are delivered. These notes are not lengthy descriptions of conversations and interactions, but a description of the intervention, the person’s response and the person’s ability to improve functioning as a result of the intervention.

    Compare progress notes A and B, below that document the same intervention of an individual ARMHS service:

    Note A:
    Mary and I met at the new coffee house in town. She was smiling and happy about seeing the new business. When we walked inside, Mary said she wanted a mocha latte to celebrate. We got our drinks and then sat down on the new patio. Mary said she wanted to congratulate the new owner, but wasn’t feeling like she could do it as everyone would be watching her. Mary started pacing in the coffee house. I discussed with Mary her feelings of inadequacy when it came to communicating with strangers. I informed her that she should consider using techniques that would calm her down and I encouraged her to do so. She drank her latte and said she wanted to go home—Now! However, she was willing to sit while I finished my coffee. We will meet next week to discuss today’s behavior at the coffee house.

    Note B (using the G-I-R-P-S narrative outline to describe a rehabilitative event):

    Goal & objective

    Goal: By using coping skills for dealing with anxiety, I will appear calm and poised in social situations with people who are new to me.

    Objective: Develop and use two coping skills that reduce pacing when I start to feel anxious.

    Intervention

    Demonstrated three ways to use the coping skill of distraction (tap wrist, blink, sit down) when feeling anxious or when pacing. Asked Mary to identify two more ways she could distract herself when she starts to feel anxious.

    Response

    Mary identified “taking three deep breaths” and humming the song, “You Are My Sunshine” as alternative actions that would distract her. She practiced all five strategies and observed that humming was probably the best one used when she was by herself.

    Plan

    Mary agreed to practice these five distraction skills and will keep a list of other strategies she thinks of posted on her refrigerator. During the next session, we will review her list and then role-play situations that have made her anxious enough to pace in the past, so that she can practice linking the anxiety with the distraction skill.

    Significant observations

    Mary stuttered today when talking about going back to school. She has not stuttered before when discussing this subject.

    As with rehabilitation, progress notes focus on functioning. Thus, Note B contains little psychiatric or psychological language and is consistent with best practices.

    ARMHS Group Documentation

    When documenting a client’s participation in an ARMHS group, the interventions used in that group must relate to the client and his/her rehabilitation goals. For example, if a client is very familiar with his medications, is adhering to a medication schedule and understands the side effects, a medication education group would not be medically necessary even if the socialization and camaraderie of a group were beneficial.

    However, the topic of a group need not be the intervention for a specific individual. For example, if the a group’s topic could be on developing a solid relapse prevention plan. An individual who may already have a relapse prevention plan, but may be practicing communication skills of not interrupting and taking turns may still be appropriate for the group. In that case, the progress note should reflect a different intervention for the group participant. The group becomes the setting for an intervention and response, rather than the basis of the intervention.

    Required Outcome Reporting

    All Minnesota ACT teams must participate in the program evaluation system. The information is used to assess outcomes associated with the program and to determine how changes in the mental health service delivery system may be affecting clients. It is also used to help guide the state’s policy and planning decisions as well as to guide service management decisions by counties, initiatives, and providers.

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