Program Requirement Four (4): Scope of Services – Screening, Assessment, and

Program Requirement Four (4): Scope of Services – Screening, Assessment, and Diagnosis A. The CCBHC directly, or through a DCO, provides screening, assessment, and diagnosis, including risk assessment for behavioral health conditions. In the event specialized services outside the expertise of the CCBHC are required for purposes of screening, assessment, or diagnosis (e.g., neuropsychological testing or developmental testing and assessment), the CCBHC refers the person to an appropriate provider. When necessary and appropriate screening, assessment and diagnosis can be provided through telehealth/telemedicine services. Note: Refer to the program requirement regarding coordination of services and treatment planning. B. Screening, assessment, and diagnosis are conducted in a time frame responsive to the needs and preferences of the person receiving services and are of sufficient scope to assess the need for all services required to be provided by the CCBHC. C. The initial evaluation (including information gathered as part of the preliminary triage and risk assessment, with information releases obtained as needed), as required in Program Requirement Two (2), includes at a minimum: 1. Preliminary diagnoses. 2. The source of referral. 3. The reason for seeking care, as stated by the person receiving services or other people who are significantly involved. 4. Identification of the immediate clinical care needs related to the diagnosis for mental and substance use disorders of the person receiving services. 5. A list of all current prescriptions and over-the counter medications, herbal remedies, and dietary supplements and the indication for any medications. 6. A summary of previous mental health and substance use disorder treatments with a focus on which treatments helped and were not helpful. 7. The use of any alcohol and/or other drugs the person receiving services may be taking and indication for any current medications. 8. An assessment of whether the person receiving services is a risk to self or to others, including suicide risk factors. 9. An assessment of whether the person receiving services has other concerns for their safety, such as intimate partner violence. 10. Assessment of need for medical care (with referral and follow-up as required). 11. A determination of whether the person presently is, or ever has been, a member of the U.S. Armed Services. 12. For children and youth, whether they have system involvement (such as child welfare and juvenile justice). D. A comprehensive evaluation is required for all people receiving CCBHC services. Subject to applicable state, federal, or other accreditation standards, clinicians should use their clinical judgment with respect to the depth of questioning within the assessment so that the assessment actively engages the person receiving services around their presenting concern(s). The evaluation should gather the amount of information that is commensurate with the complexity of their specific needs and prioritize preferences of people receiving services with respect to the depth of evaluation and their treatment goals. The evaluation shall include: 1. Reasons for seeking services at the CCBHC, including information regarding onset of symptoms, severity of symptoms, and circumstances leading to the presentation to the CCBHC of the person receiving services. 2. An overview of relevant social supports; social determinants of health; and health related social needs such as housing, vocational, and educational status; family/caregiver and social support; legal issues; and insurance status. 3. A description of cultural and environmental factors that may affect the treatment plan of the person receiving services, including the need for linguistic services or supports for people with LEP. 4. Pregnancy and/or parenting status. 5. Behavioral health history, including trauma history and previous therapeutic interventions and hospitalizations with a focus on what was helpful and what was not helpful in past treatments. 6. Relevant medical history and major health conditions that impact current psychological status. 7. A medication list including prescriptions, over-the counter medications, herbal remedies, dietary supplements, and other treatments or medications of the person receiving services. Those identified in a Prescription Drug Monitoring Program (PDMP) that could affect their clinical presentation and/or pharmacotherapy, as well as information on allergies including medication allergies, should be included. 8. An examination that includes current mental status, mental health (including depression screening, and other tools that may be used in ongoing measurement-based care) and substance use disorders (including tobacco, alcohol, and other drugs). 9. Basic cognitive screening for cognitive impairment. 10. Assessment of imminent risk, including suicide risk, withdrawal and overdose risk, danger to self or others, urgent or critical medical conditions, and other immediate risks including threats from another person. 11. The strengths, goals, preferences, needs, and other factors to be considered in treatment and recovery planning of the person receiving services. 12. Assessment of the need for other services required by the statute (i.e., peer and family/caregiver support services, targeted case management, psychiatric rehabilitation services). 13. Assessment of any relevant social service needs of the person receiving services, with necessary referrals made to social services. For children and youth receiving services, assessment of systems involvement such as child welfare and juvenile justice and referral to child welfare agencies as appropriate. 14. An assessment of need for a physical exam or further evaluation by appropriate health care professionals, including the primary care provider (with appropriate referral and follow-up) of the person receiving services. 15. The preferences of the person receiving services regarding the use of technologies such as telehealth/telemedicine, video conferencing, remote patient monitoring, and asynchronous interventions. E. Screening and assessment conducted by the CCBHC related to behavioral health include those for which the CCBHC will be accountable pursuant to Program Requirement Five (5) and Rule 54.33 of these criteria. The CCBHC should not take non-inclusion of a specific metric in Rule 54.33 as a reason not to provide clinically indicated behavioral health screening or assessment. F. The CCBHC uses standardized and validated and developmentally appropriate screening and assessment tools appropriate for the person and, where warranted, brief motivational interviewing techniques to facilitate engagement. G. The CCBHC uses culturally and linguistically appropriate screening tools and approaches that accommodate all literacy levels and disabilities (e.g., hearing disability, cognitive limitations), when appropriate. H. If screening identifies unsafe substance use including problematic alcohol or other substance use, the CCBHC conducts a brief intervention and the person receiving services is provided a full assessment and treatment, if appropriate within the level of care of the CCBHC or referred to a more appropriate level of care. If the screening identifies more immediate threats to the safety of the person receiving services, the CCBHC will take appropriate action as described in Program Requirement Two (2).