Scope of Services

(A) The CSP provider delivers CSP services on a mobile basis to members in any setting that is safe for the member and staff. Services may be provided via telehealth, as appropriate. (B) A community support program must have the capacity to provide at least the following service components: (1) Intake Services. (a) The program must initiate service planning immediately by communicating with the referral source, if any, to determine goals, and document appropriateness of services. (b) If the member is referred by a 24-hour behavioral health level of care, including inpatient and diversionary providers, the program will participate, as appropriate, in member discharge planning at the referring provider. (c) If, during intake, the member is determined to be ineligible for CSP services pursuant to 130 CMR 461.403, the program must provide referrals to alternative services that may be medically necessary to meet the member’s needs, if any. (2) Needs Assessment. The program must conduct a needs assessment for every member as follows: (a) The needs assessment must be completed within two (2) weeks of the initial appointment. (b) The needs assessment must be updated with the member quarterly, at a minimum, or more frequently if needed, and must be entered in the member’s health record. (c) The needs assessments must identify ways to support the member in mitigating barriers to accessing and utilizing clinical treatment services, and attaining the skills and resources to maintain community tenure. (d) For CSP-JI, the needs assessment also must also include determination of Criminogenic Needs. (e) For Specialized CSP, the timeframes for completing and updating the needs assessment may be extended as needed to allow for member engagement if the provider documents timely, yet unsuccessful, efforts to engage the member in completing or updating the assessment. (3) Service Planning. The program must complete a service plan for every member upon completion of the comprehensive needs assessment as follows: (a) The service plan must be person-centered and identify the member’s needs and individualized strategies and interventions for meeting those needs; (b) As appropriate, the service plan must be developed in consultation with the member and member’s chosen support network including family, and other natural or community supports; (c) As appropriate, the program must incorporate available records from referring and existing providers and agencies into the development of the service plan, including any bio-psychosocial assessment, reasons for referral, goal, and discharge recommendations. (d) The service plan must be in writing, and must include at least the following information, as appropriate to the member’s presenting complaint: 1. Identified problems and needs relevant to services; 2. The member’s strengths and needs; 3. A comprehensive, individualized plan that is solution-focused with clearly defined interventions and measurable goals. 4. Identified clinical interventions, services, and benefits to be performed and coordinated by the provider; 5. Clearly defined staff responsibilities and assignments for implementing the plan; 6. The date the plan was last reviewed or revised; and 7. The signatures of the CSP staff involved in the review or revision. (e) The service plan must be reviewed and revised at least every 12 months. The service plan must be updated if there are significant changes in the member’s needs, by reviewing and revising the goals and related activities. (4) Community Support Program Services. These services include those provided by the CSP staff to the member and supervised by the staff identified in 130 CMR 461.411. CSP services must foster member empowerment, recovery, and wellness and must be designed to increase a member’s independence, including management of their own behavioral health and medical services. Services vary over time in response to the member’s ability to use their strengths and coping skills and achieve these goals independently. Services include: (a) Assisting members in improving their daily living skills so they are able to perform them independently or access services to support them in doing so; (b) Spending time with members and providers; (c) Providing members and their families with education, educational materials, and training about behavioral health and substance use disorders and recovery. The provider facilitates access to education and training on the effects of psychotropic medications, and ensures that the member is linked to ongoing medication monitoring services and regular health maintenance; (d) Coordinating services and assisting members with obtaining benefits, housing, and healthcare; (e) Communicating with members or other parties that may include appointment reminders or coordination of care; (f) Collaborating with crisis intervention providers, state agencies, and outpatient providers, including working with these providers to develop, revise, and utilize member crisis prevention plans and safety plans; and (g) Encouraging and facilitating the utilization of natural support systems, and recovery- oriented, peer support, and self-help supports and services. (5) Referral Services. The program must have effective methods to promptly and efficiently refer members to community resources. The program must have knowledge of and connections with resources and services available to members. (a) Each program must have written policies and procedures for addressing a member’s behavioral health disorder needs that minimally include personnel, referral, coordination, and other procedural commitments to address the referral of members to the appropriate health care providers. (b) When referring a member to another provider for services, each program must ensure continuity of care, exchange of relevant health information, and avoidance of service duplication between the CSP provider and the provider to whom a member is referred. Each program must also ensure that the referral process is completed successfully and documented. (c) Referrals should result in the member being directly connected to and in communication with community resources for assistance with housing, employment, recreation, transportation, education, social services, health care, outpatient behavioral health services, and legal services. (6) Crisis Intervention Referrals. During business hours or outside business hours, each program must have capacity to respond to a member’s behavioral health crisis. Under the guidance of a CSP supervisor, the CSP staff may implement interventions to support and enable the member to remain in the community, refer the member to crisis intervention services, or refer the member to other healthcare providers, as appropriate. (7) Discharge Planning. The program must provide discharge planning for each member receiving CSP to expedite a member-centered disposition to other levels of care, services, and supports, as appropriate. Discharge from the program occurs in accordance with the clinical standards published by the MassHealth agency. (a) The provider shall begin discharge planning upon admission of the member into the CSP, with the participation of the member, and shall document all discharge planning activity in progress notes in the member’s health record; (b) As appropriate and applicable, the discharge planning process must involve the member’s natural and community supports, current and anticipated future providers, current and anticipated future involved services agencies, and probation or parole staff. (c) The discharge planning process must include crisis prevention and safety planning. (d) The program shall ensure that a written CSP discharge plan is given to the member at the time of discharge along with the updated service plan and a copy is entered in the member’s health record. With member consent, a copy of the written discharge plan shall be forwarded at the time of discharge to the following individuals or entities involved in or engaged with the member’s ongoing care: family members, guardian, caregiver, and significant other; state agencies; outpatient or other community-based provider; physician; school; crisis intervention providers; probation, parole; and other entities and agencies that are significant to the member’s aftercare. (C) Additional Services Provided through Specialized Community Support Programs (1) CSP-HI Services. CSP-HI includes assistance from specialized professionals who have the ability to engage and support individuals experiencing homelessness in searching for permanent supportive housing; preparing for and transitioning to an available housing unit; and, once housed, coordinating access to physical health, behavioral health, and other needed services geared towards helping them sustain tenancy and meet their health needs. In addition to the service components set forth in 130 CMR 461.410(A) and (B), CSP-HI services must also include (a) pre-tenancy supports, including engaging the member and assisting in the search for an appropriate and affordable housing unit; (b) support in transition into housing, including assistance arranging for and helping the member move into housing; and (c) tenancy sustaining supports, including assistance focused on helping the member remain in housing and connect with other community benefits and resources. (2) CSP-TPP Services. CSP-TPP provides tenancy sustaining services, including tenant rights education and eviction prevention. In addition to the service components set forth in 130 CMR 461.410(A) and (B), CSP-TPP services must also include (a) assessing the underlying causes of the member’s Eviction, and identifying services to address both the lease violation and the underlying causes; (b) developing a service plan to maintain the tenancy; (c) Providing clinical consultation services as well as short term, intensive case management and stabilization services to members; and (d) Making regular reports to all parties involved in the Eviction until the member’s housing situation is stabilized. (3) CSP-JI Services. In addition to the service components set forth in 461.410(A) and (B), CSP-JI includes (a) if the referral source is a correctional institution, coordinating with the BH-JI provider conducting in-reach services; (b) ensuring that the CSP-JI service plan does not conflict with the member’s probation and parole supervision plan, as applicable; and (c) addressing the member’s criminogenic needs in the service plan goals, including interventions and strategies for developing alternative behaviors.