CRISIS SERVICES
crisis services
State Authorization: /G. S. §122C147.1; S.L. 200666 (Senate Bill 1741), Part X, Section 10.26 (a) - (f); S.L. 2007-323 (House Bill 1473), Part X, Section 10.49; S.L.2008-107 (House Bill 2436), Part X, Section 10.15 (l) (m); S.L. 2009-451 (Senate Bill 202), Part X, Section 10.12(b); S.L. 2014 (Senate Bill 744), Section 12F.5.
N. C. Department of Health and Human Services
Division of Mental Health, Developmental Disabilities and Substance Abuse Services
Flo Stein, Chief
Community Policy Management
NC Division of MH/DD/SAS
3007 Mail Service Center
Raleigh, NC 27699-3007
(919) 733-4670
Agency Contact Person – Financial
Kent Woodson
Financial Operations
NC Division of MH/DD/SAS
3013 Mail Service Center
Raleigh, NC 27699-3013
Phone: (919) 733-7013 ext. 2004
/ N. C. DHHS Confirmation Reports:
SFY 2015 audit confirmation reports for payments made to Counties, Local Management Entity -Managed Care Organizations (LME-MCOs), Boards of Education, Councils of Government, District Health Departments and DHSR Grant Subrecipients will be available by early September at the following web address: http://www.ncdhhs.gov/control/auditconfirms.htm. At this site, click on the link entitled “Audit Confirmation Reports (State Fiscal Year 2013-2014)”. Additionally, audit confirmation reports for Nongovernmental entities receiving financial assistance from the DHHS are found at the same website except select “Non-Governmental Audit Confirmation Reports (State Fiscal Years 2013-2015)”.
The Auditor should not consider the Supplement to be “safe harbor” for identifying audit procedures to apply in a particular engagement, but the Auditor should be prepared to justify departures from the suggested procedures. The Auditor can consider the Supplement a “safe harbor” for identification of compliance requirements to be tested if the Auditor performs reasonable procedures to ensure that the requirements in the Supplement are current. The grantor agency may elect to review audit working papers to determine that audit tests are adequate.
I. PROGRAM OBJECTIVES
In July 2006, the General Assembly designated $5.2 million for LMEs to develop long-term plans and for operational start-up of local crisis services (Session 2006, Senate Bill 1741). Additional funds provided in S.L. 2007-323 (House Bill 1473, Section 10.49) were designated for continued implementation of these plans. Over State fiscal years 2007 and 2008, each LME developed a long-term plan and worked with providers to establish new crisis services. The goals of this program are to:
Expand Crisis Services:
· Crisis funds available to DHHS are to be allocated to LME/MCOs to continue to implement the crisis plans developed.
· Crisis funds available to DHHS are to be allocated to LME/MCOs to continue increasing the crisis services available throughout the State of North Carolina.
· Crisis services are to be made available to all age and disability groups, and are to be allocated as non-disability specific general services funds.
· Directs DHHS to develop a system for reporting on crisis visits to community hospital emergency departments.
Facility-Based Crisis Services – Currently a service for adults with efforts on hold to expand the service to children and adolescents. Professional Treatment Services in a Facility-Based Crisis Program is a service persons who have a mental illness, intellectual/developmental disability (IDD), and/or substance abuse disorder and is provided in a 24-hour residential facility, licensed under 10A NCAC 27G .5000, with 16 beds or less, designated as an involuntary treatment facility by DHHS in accordance with 10A NCAC 26C .0100. The Facility-Based Crisis Program is under the clinical oversight of a psychiatrist. This is a short term service that provides disability-specific care and treatment in a non-hospital setting for individuals requiring acute crisis stabilization. This crisis stabilization service includes a comprehensive clinical assessment, treatment intervention, behavior management or support plan, and aftercare planning. This service is designed as a timelimited alternative to hospitalization for an individual in crisis.
· Local Inpatient Services – Psychiatric inpatient services located in community hospitals. These hospitals have designated psychiatric units. Services are provided through a 3-way contract between DHHS-DMH/DD/SAS, the LME and the local hospital contractor.
· Mobile Crisis Team – Mobile Crisis Management (MCM) services are delivered by members of a multidisciplinary team to provide integrated crisis response 24 hours a day, 7 days a week, 365 days a year. MCM is a short-term, situational crisis response service, not an ongoing treatment service. MCM services are offered face-to-face in the community to de-escalate and stabilize crisis events, with the goal of preventing psychiatric hospitalization. Services also include immediate telephonic triage, as well as assistance to the recipient to gain access and safe transition to clinically necessary mental health, developmental disabilities, and/or substance abuse services; treatment and supports for symptom reduction; and crisis stabilization.
· Crisis Respite Beds – Crisis Respite may be used when a person cannot be safely supported in their home due to his/her behavior and implementation of formal behavior interventions have failed to stabilize the behaviors and/or all other approaches to insure health and safety have failed. In addition, the service may be used as a planned respite stay for waiver participants who are unable to access regular respite due to the nature of their behaviors.
· Detox Services – A continuum of services designed for the safe detoxification is an organized service delivered by medical and nursing professionals that provides for 24-hour medically supervised evaluation and withdrawal management in a permanent facility affiliated with a hospital or in a freestanding facility of 16 beds or less. Services are delivered under a defined set of physician-approved policies and physician-monitored procedures and clinical protocols.
· After-Hour Crisis Services – 24/7/365 telephone access operated by the LMEs. Licensed professionals are available to triage and refer persons in crisis to any of these other services in the crisis continuum.
· Transition Beds – A transitional residential treatment program which provides 24-hour residential treatment and rehabilitation for adults who have a pattern of difficult behaviors related to mental illness which exceeds the capabilities of traditional community residential settings.
· Walk-In Crisis Services – At a walk-in site an adult, adolescent, or family in crisis can receive immediate care. The care may include an assessment and diagnosis for mental illness, substance abuse, and developmental disability issues as well as planning and referral for future treatment. Other services may include medication management, outpatient treatment, and short-term follow-up care. Psychiatric aftercare may also assist consumers returning to the community from a state psychiatric hospital or alcohol and drug abuse treatment center until they are established with a local clinical provider.
· Peer Support Services – A community-based service for adults age eighteen (18) and older who have a mental illness or a substance abuse disorder. PSS is provided by a Certified Peer Support Specialist who has self-identified as a person in recovery from mental illness or substance abuse issues and is committed to his or her own recovery. PSS provides structured, scheduled activities that promote recovery, self-determination, self-advocacy, and enhancement of community living skills. Peer Support Service is an individualized, recovery-focused service, based on a relationship of mutuality that allows the individual an opportunity to learn to manage his or her own recovery.
· Emergency Department Safe Areas – A block or rooms or areas in community hospitals that are created specifically for persons experiencing psychiatric crises. The set up varies from hospital to hospital but all involve close observation in a safe protected setting.
· Telemedicine and/or Telepsychiatry – A broad term referring to the provision of mental health care from a distance. Telemedicine for mental health includes mental health assessment, treatment, education, monitoring, and collaboration. Patients can be located in hospitals, clinics, schools, nursing facilities, prisons and homes. TMH providers and staff include psychiatrists, nurse practitioners, physician assistants, social workers, psychologists, counselors, primary care providers and nurses. The goal of the telemedicine provider is to eliminate disparities in patient access to quality, evidence-based, and emerging health care diagnostics and treatments.
· North Carolina Systemic, Therapeutic Assessment, Respite and Treatment (NC START) – North Carolina Session Law 2008 appropriated funds to implement NC START, an evidenced-based model of community based crisis prevention and intervention services for people with Intellectual/Developmental Disabilities (I/DD) who are at least 18 years of age and who experience crises due to mental health or complex behavioral health issues. The goal of NC START is to create a support network that is able to respond to crisis needs at the community level. The emphasis and focus of NC START is on prevention of crisis through identification of high risk individuals, and on crisis planning and prevention with detailed follow up of individuals served. A primary focus of the teams is to prevent unnecessary use of emergency mental health and psychiatric inpatient service for individuals with IDD and mental illness or challenging behaviors. Providing community based, person centered supports that enable individuals to remain in their home or community placement is the first priority.
· 3 Way Contracts – The Division, LME-MCOs, and select hospitals have entered into contracts for the purchase of local inpatient bed days to divert those individuals requiring short term stays from state psychiatric hospitals. The services will be billed under the service code YP821 (3 way hospital bed day) or YP822 (enhanced 3 way hospital bed day). For SFY 2013-2014 hospitals were reimbursed at $750 per bed day for YP821 services and $900 per bed day for YP822 services.
Suggested Audit Procedures
a. Sample services and verify that all providers being reimbursed for YP821 and/or YP822 have a valid contract covering the term in which the service was provided.
b. From the verified sample set, test to ensure that rates for YP821 and YP822 were not supplemented from other payment sources.
II. PROGRAM PROCEDURES
Expand Crisis Services:
Implementation of the Crisis Plans
· There is written evidence of a Division approved crisis plan by which LME/MCOs within a crisis region shall work together to identify gaps in their ability to provide a continuum of crisis services for all consumers and use the funds allocated to them to develop and implement a plan to address those needs. At a minimum, the plan must address the development over time of the following components: 24hour crisis telephone lines, walkin crisis services, mobile crisis outreach, crisis respite/residential services, crisis stabilization units, 24hour beds, facilitybased crisis, inpatient crisis, detox, and transportation. Options for voluntary admissions to a secured facility must include at least one service appropriate to address the mental health, developmental disability, and substance abuse needs of adults, and the mental health, developmental disability, and substance abuse needs of children. Options for involuntary commitment to a secured facility must include at least one option in addition to admission to a State facility.
· There is written evidence that if LME/MCOs in a crisis region determine that a facilitybased crisis center is needed and sustainable on a longterm basis, the crisis region shall first attempt to secure those services through a community hospital or other community facility. This written evidence shall document that if all the LME/MCOs in the crisis region determine the region’s crisis needs are being met, the LME/MCOs may use the funds to meet local crisis service needs.
Increasing the Crisis Services
· There is written evidence that LME/MCO’s shall work with sheriffs and county public health agencies to serve individuals who are incarcerated or being held in county jails and who are in need of crisis services.
Implementation of NC START
· Each of the providers was required to submit an implementation plan outlining how the elements of the NC START model would be implemented.
· A comprehensive template and corresponding data base has been developed for quarterly reporting by the regional clinical teams and respite homes through the host LME/MCOs who in turn submit the data to DMH/DD/SAS and DSOHF. Broad reporting components include: Information on individuals served, referral and crisis intervention services provided, planned services and training/education provided, and respite home utilization.
III. COMPLIANCE REQUIREMENTS
Crosscutting Requirements
The DHHS/Division of Mental Health, Developmental Disabilities and Substance Abuse Services (DMH/DD/SAS) mandates that all the testing included within the crosscutting section be performed by the local auditors. Please refer to that section, which is identified as “DMH-0” for those mandated requirements.
1. Activities Allowed or Unallowed
Compliance Requirement
There is written evidence that these funds shall be used to develop a continuum of crisis services for all consumers in the LME/MCO’s catchment area. At a minimum, these services include the following components: 24hour crisis telephone lines, walkin crisis services, mobile crisis outreach, crisis respite/residential services, crisis stabilization units, 24hour beds, facilitybased crisis, inpatient crisis, detox, and transportation. In addition, there shall be at least one service appropriate to address the MH/DD/SA needs of adults and of children respectively in a secured facility. Provision shall also be made for the availability of at least one secured facility to treat individuals under petition of involuntary commitment as an alternative to admission to a State facility.
For NC START there is written evidence that these funds shall be used to develop and implement NC START services according to the required components of the model. At a minimum there must be six crisis/clinical teams; two teams per region of the state and twelve respite beds; four per region.
Audit Objectives
a. Determine whether funds were expended only for allowable activities.
Suggested Audit Procedures:
a. Crisis services funds are disbursed on a UCR and Non-UCR basis three way contract funds are located in 1464 536996001. Additional funds totaling $8.5 million statewide will be allocated in late SFY2015 in separate accounts ending with sub-account designation of ‘010’ at the time of publication of this supplement, those specific account and allocation have not been assigned. Sample local documentation on individual client record to verify that clients were enrolled in the Common Name Data System (CNDS), the Consumer Data Warehouse (CDW) and an approved NCTracks benefit plan and that services were provided.
b. Verify that expenditures are in accordance with any restrictions noted on the allocation letter and that any requested reports requested on the allocation letter have been submitted to the Division. In reference to those funds ending in ‘010’ these expenditures must be in accordance with the state approved plan submitted by the LME. These approved plans can be obtained by contacting Crystal Farrow at (919) 715-1294 or via email at .