Specialized Rehabilitative Services and Specialized Services

Specialized Rehabilitative Services and Specialized Services A. Specialized rehabilitative services are defined as rehabilitative services which a nursing facility (NF) is required to provide to meet the daily physical, social, functional or mental health needs of its persons and include, but are not limited to: 1. Physical therapy, 2. Speech/language therapy, 3. Occupational therapy, and 4. Mental Health Rehabilitative Services for mental illness (MI) and/or intellectual disability/development disability (ID/DD). B. The NF must provide the specialized rehabilitative services necessary for the well-being of its persons even if the specialized rehabilitative services are not specifically mentioned in the Medicaid State Plan and cannot charge the person a fee for the specialized rehabilitative services because they are covered NF services. C. A NF is not obligated to provide specialized rehabilitative services if no current person requires the services but if a resident develops the need for a specialized rehabilitative service after admission, the NF must either provide the specialized rehabilitative service or obtain the service from an outside resource. D. Mental health rehabilitative services for MI, ID/DD and/or a related condition (RC) are specialized rehabilitative services which the NF is required to provide to meet the daily mental health needs of its persons. These services include, but are not limited to: 1. Consistent implementation, during the person’s daily routine and across settings, of systematic plans which are designed to change inappropriate behaviors, 2. Administering and monitoring the effectiveness and side effects of medications which are prescribed to change inappropriate behavior or to alter manifestations of psychiatric illness, 3. Provision of a structured environment for those persons who are determined to need structure such as structured socialization activities to diminish tendencies toward isolation and withdrawal, 4. Development, maintenance, and consistent implementation across settings of those programs designed to teach persons the daily living skills they need to be more independent and self-determining. Program focus may include but not be limited to grooming, personal hygiene, mobility, nutrition, health, medication management, mental health education, money management, and maintenance of the living environment, 5. Development of appropriate personal support networks, or 6. Formal behavior modification programs. E. If mental health rehabilitative services for MI, ID/DD and/or RC services are needed by a person, they must be provided by the NF regardless of whether the need was identified through the PASRR process, and regardless of whether the person requires other specialized services through another Medicaid provider. F. Specialized Services for persons with MI are the services specified by the ARC that include treatment other that routine nursing care, supportive therapies, and supportive counseling by NF staff. This includes services that, combined with services provided by the NF, result in the continuous and aggressive implementation of an individualized plan of care that will aid the person in attaining the highest practicable level of physical, mental and psychosocial well-being, and: 1. Is developed and monitored by an interdisciplinary team, which includes a physician, qualified mental health professionals and, as appropriate, other professionals; 2. Prescribes specific therapies and activities for the treatment of person experiencing an acute episode of serious MI, which necessitates supervision by trained mental health personnel; and 3. Is directed toward the diagnosis and reduction of the person’s behavioral symptoms that necessitate institutionalization and that aid the person to improve his/her level of independent functioning, and achieve a functioning level that permits reduction in the intensity of mental health services to below the level of specialized services at the earliest possible time. G. Specialized services for persons with MI provided by Community Mental Health Centers (CMHCs) or Private Mental Health Centers (PMHCs) include, but are not limited to: 1. Medication Evaluation and Monitoring defined as an intentional face-to-face interaction between a physician or a nurse practitioner and a person for the purpose of assessing the need for psychotropic medication, prescribing medications and regular periodic monitoring of the medications prescribed for therapeutic effect and medical safety, 2. Individual Therapy defined as one-on-one psychotherapy that takes place between a mental health therapist and a person, 3. Family Therapy defined as psychotherapy that takes place between a mental health therapist and a person’s family members, with or without the presence of the person. Family therapy may also include others with whom the resident has a family-like relationship. However, meetings with NF staff that do not include the person is not considered family therapy, 4. Group Therapy defined as psychotherapy that takes place between a mental health therapist and at least two (2), but no more that twelve (12) residents at the same time. Possibilities include, but are not limited to, groups that focus on coping with or overcoming depression, adaptation to changing life circumstances and self-esteem enhancement, and 5. Psychosocial Rehabilitation defined as a program of structured activities, designed to support and enhance the ability of NF persons to function at the highest possible level of independence. The structured activities target the specific needs and concerns of the NF persons and aim to improve reality orientation, social adaptation, physical coordination, daily living skills, time and resource management, task completion and other areas of competence that promote independence in daily life. Structured activities are designed to aid in alleviating such psychiatric symptoms as confusion, anxiety, disorientation, distraction, preoccupation, isolation, withdrawal and feelings of low self-worth. H. Specialized services for persons with MI, ID/DD and/or RCs include, but are not limited to, specialized services that constitute a continuous active treatment program, that includes aggressive, consistent implementation of a program of specialized and generic training, treatment, health services and related services directed toward: 1. The acquisition of the behaviors necessary for the person to function with as much self- determination and independence as possible. 2. The prevention or deceleration of regression or loss of current optimal functional status. Specialized services are not services provided to maintain generally independent clients who are able to function with little supervision or in the absence of a continuous active treatment program. 3. Short-term provision of any one (1) or a combination of the following services for the person during the temporary acute and/or sub-acute need: a) Inpatient psychiatric services, b) Medication evaluation and monitoring by a psychiatrist or similarly credentialed professional, such as a Psychiatric Nurse Practitioner, to evaluate patient response to psychotropic medications and to modify medication orders, c) Individual, family, and/or group therapy services, and d) Psychosocial rehabilitation services, and e) Senior psychosocial rehabilitation. I. Specialized services provided by community service providers certified by DMH include, but are not limited to: 1. Training targeted toward amelioration of identified basic skill deficits and/or maladaptive behavior, 2. Priority training needed to achieve greater levels of independence and self-determination, and 3. Aggressive implementation of a systematic program of formal and informal techniques and competent interactions continuously targeted toward achieving a measurable level of skill competency specified in written objective, based on a comprehensive interdisciplinary evaluation, and conducted in all client settings and by all personnel involved with the person. J. The Division of Medicaid considers specialized services as any disability related supports and services provided to a NF person with a PASRR condition that aids the person to attain the highest practicable level of physical, mental, and psychosocial well-being that includes, but is not limited to: 1. A short-term intensive intervention for a maximum of six (6) months promoting the successful adaptation to the NF and/or to improve the resident’s quality of life during the NF stay. 2. A short-term intensive intervention, that promotes a successful NF discharge and community reintegration, for persons with a capacity for community reintegration, within the ensuing three (3) to six (6) month period. These services are provided to promote the mission of Olmstead and other similar reintegration and diversion initiatives promoting successful community reintegration through targeted, time-limited, and goal directed services for persons with ID/DD who have the capacity for such transition. 3. Services include short-term services for a maximum of six (6) months depending on the identified needs of the person with the provision of one (1) or a combination of the following services that include, but are not limited to: a) Independent living skills development, b) Community living/integration skills development, c) Re-socialization skills development, and d) Behavior support and intervention services.