CCBHC State Collected Measures

CCBHC State Collected Measures A. CCBHCs are required to report on state collected measures. Data specifications are provided by DMH. B. The required State Collected Measures for CCBHC Clinics are as follows: 1. Adherence to Antipsychotic Medications for Individuals with Schizophrenia (SAA- AD). 2. Antidepressant Medication Management (AMM-BH). 3. Follow-Up After Emergency Department Visit for Alcohol and Other Drug Dependence (FUA-CH and FUA-AD). 4. Follow-Up After Emergency Department Visit for Mental Illness (FUM-Ch and FUM- AD). 5. Follow-Up After Hospitalization for Mental Illness, ages 18+ (adult) (FUH-AD). 6. Follow-Up After Hospitalization for Mental Illness, ages 6-17 (child/adolescent) (FUH-CH). 7. Follow-Up Care for Children Prescribed Attention-Deficit Hyperactivity Disorder (ADHD) Medication (ADD-CH). 8. Hemoglobin A1c Control for Patients with Diabetes (HBD-AD). 9. Initiative and Engagement of Alcohol and Other Drug Dependence Treatment (IET- AD). 10. Metabolic Monitoring for Children and Adolescents on Antipsychotic (APM-CH). 11. Patient Experience of Care Survey. 12. Plan All-Cause Readmissions Rate (PCR-AD). 13. Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP-CH). 14. Use of Pharmacotherapy for Opioid Use Disorder (OUD-AD). 15. Youth/Family Experience of Care Survey. 16. Mental Health Utilization (MPT). Number and percentage of people receiving mental health services by service type (e.g., any service inpatient, intensive outpatient/partial hospitalization, outpatient or Emergency Department). For people receiving Behavioral Health Services and enrolled in high-risk Care Management: Treatment plan: number and percentage of people receiving Behavioral Health/Substance Use Disorder Services with a treatment plan (therapy, medication, etc.) Number of emergency department visits for people receiving Behavioral health/Substance Use Disorder Services. Source: Miss. Code Ann. § 41-4-7 This page intentionally left blank. Part 2: Chapter 55: Glossary A. Agency Provider: The overall agency provider/entity. Agency provider does not refer to an individual employee or service location. Agency provider may refer to an overall agency which is interested in obtaining DMH certification (i.e., Interested Agency Provider) or an existing DMH-certified agency provider. B. Approved Educational Institution: A degree-granting institution of higher learning which is accredited by a Council for Higher Education Accreditation (CHEA)- recognized and/or a United States Department of Education (USDE)-recognized accrediting body. C. Assertive Engagement: The use of interpersonal skills, continuity of care strategies, and inventiveness by providers to engage people, connect them with appropriate subsequent care as needed, and initiate such care. Assertive engagement utilizes techniques such as a “warm handoff” to the person’s next level of care provider and promotes people staying connected to treatment. D. Care Coordination: Providers establish activities within their organization and with care coordination partners that promote clear and timely communication, deliberate coordination, and seamless transition. This may include (but is not limited to): 1. Establishing accountability and agreeing on responsibilities between care coordination partners. 2. Engaging and supporting people receiving services in, and subject to, appropriate consent, their family, and caregivers, to participate in care planning and delivery and ensuring that the supports and services that the person receiving services and family receive are provided in the most seamless manner that is practical. 3. Communicating and sharing knowledge and information, including the transfer of health records and prescriptions, within care teams and other care coordination partners, as allowable and agreed upon with the individual person being served. 4. Coordinating and supporting transitions of care that include tracking of admission and discharge and coordination of specific services if the person receiving services presents as a potential suicide or overdose risk. 5. Assessment of the needs and goals of the person receiving services to create a proactive treatment plan and linkage to community resources. 6. Monitoring and follow-up, including adapting supports and treatment plans as needed to respond to changes in the needs and preferences of people being served. 7. Coordinating directly with external providers for appointment scheduling and follow- up after appointment for any prescription changes or care needs (i.e., “closing the loop”). 8. Communicating and sharing knowledge and information to the full extent permissible under HIPAA and CMS interoperability regulations on information blocking without additional requirements unless based on state law. As utilized in this context, care coordination applies to activities by providers that have the purpose of coordinating and managing the care and services furnished to each person receiving services (including both behavioral and physical health care), regardless of whether the care and services are provided directly by the provider or through referral or other affiliation with care providers and facilities outside the provider. Care coordination is regarded as an activity rather than a service. E. Certified Community Behavioral Health Clinic (CCBHC) or Clinic: A CCBHC is a qualifying clinic that is responsible for providing all nine (9) services in a manner that meets or exceeds CCBHC criteria as outlined in this manual. CCBHCs deliver the nine (9) required services directly or through formal agreements with DCOs. CCBHCs have the capacity to provide directly mental health and substance use services to people with serious mental illness and serious emotional disorders as well as developmentally appropriate mental health and substance use care for children and youth separate from any DCO relationship, unless substantially prohibited because of their provider type. F. Certified Peer Support Specialist Professional (CPSSP): A person who has obtained and maintains the Certified Peer Support Specialist Professional (CPSSP) credential through the Mississippi Department of Mental Health. The CPSSP credentialing program includes competency-based training and testing. There are six (6) Certified Peer Support Specialist Professional credential designations: Mental Health, Substance Use, Youth/Young Adult, Parent/Caregiver, Forensics, and Peer Bridger. A Certified Peer Support Specialist Professional is a person who self-identifies as a peer and uses their lived experiences to support people receiving behavioral health services. G. Chemical restraint: A chemical restraint is a medication used to control behavior or to restrict the person’s freedom of movement and is not standard treatment of the person’s medical or psychiatric condition. A chemical restraint incapacitates a person, rendering them unable to function because of the medication. H. Community-based: Services and supports are located in, or strongly linked to, the community, and in the least restrictive setting supportive of a person's safety and treatment needs. Services and supports should be delivered responsibly and seamlessly where the person lives, works, learns, and interacts. “Community-based” further refers to the services/supports and/or programs which the Mississippi State Board of Mental Health or the Mississippi Department of Mental Health designates as being required to be delivered in the community and may be related to provider type. I. Community Needs Assessment: A systematic approach to identifying community needs and determining program capacity to address the needs of the population being served. These assessments identify current conditions and desired services or outcomes in the community, based on data and input from key community stakeholders. J. Complaint: A written allegation of misconduct or rules violation filed with DMH by any party in the manner for complaints filing, as prescribed for by DMH. K. Controlled Setting: Components for a “controlled” setting for IDD Services is defined as an agency with a lease or agreement with a property owner, and the property owner maintains control of the physical setting/environment. L. Cultural competency: Cultural competency describes the ability of an agency provider to provide services to people with diverse values, beliefs, and behaviors, including tailoring service delivery to meet the person’s social, cultural, and linguistic needs. Cultural competency is the acceptance and respect for difference, continuing self- assessment regarding culture, attention to dynamics of difference, ongoing development of cultural knowledge and resources and flexibility within service models to work towards better meeting the needs of diverse and minority populations. Cultural and linguistic competence further refers to providing effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs. Culturally and linguistically appropriate services are respectful of and responsive to the health beliefs, practices, and needs of diverse people. M. Days: A measurement of counting prescribed timelines; “days” may refer to calendar days or business days, as outlined in this document. When this distinction is not made, then “days” refers to calendar days. N. De-escalation: Verbal and non-verbal communication skills aimed at reducing another person’s agitation and aggression. De-escalation reduces the intensity of the conflict or a potential violent situation. O. DMH Credentials: Generic term referring to any or all levels of DMH professional certification/licensure; examples include (not an exhaustive list): DMH Certified Mental Health Therapist (CMHT), DMH Certified Intellectual and Developmental Disabilities Therapist (CIDDT), and DMH Certified Addictions Therapist (CAT). P. Face-to-Face Service Provision: When used within the context of the DMH Operational Standards, “face-to-face” provision of services, refers to live, in-person service provision. Q. Family/Family Members: Family/Family members include spouse, parent, stepparent, sibling, child, or stepchild. R. Grievance: A written, electronically submitted, or verbal statement made by a person receiving services (and/or parent(s)/legal representative(s)) alleging a violation of rights or policy or provider certification rule. S. Imminent Danger: 1) A strong probability that certain behaviors will occur (e.g., continued alcohol or drug use or relapse, or noncompliance with psychiatric medications); 2) The likelihood that these behaviors will present a significant risk of serious adverse consequences to the person and/or others (as in a consistent pattern of driving while intoxicated, or a re-emergence of psychiatric symptoms in a person with a psychosis); and 3) the likelihood that such adverse events will occur in the very near future. T. Indigent: People seeking substance use prevention, treatment, and/or recovery support services who are underserved, uninsured, underinsured, and/or have no ability to pay for services. A person’s indigent status is determined by the completion of an Eligibility Determination Application in accordance with Federal Poverty Guidelines (200% Threshold). Poverty Guidelines | (hhs.gov). U. Legal representative: The legal guardian or conservator for a person as determined in a court of competent jurisdiction. V. Limited English Proficiency (LEP): LEP describes a characteristic of people who do not speak English as their primary language or who have a limited ability to read, write, speak, or understand English and who may be eligible to receive language assistance with respect to the service, benefit, or encounter. W. Lived Experience: People with lived experience are people directly impacted by a social issue or combination of issues who share similar experiences or backgrounds and can bring the insights of their experience to inform and enhance systems, research, policies, practices, and programs that aim to address the issue(s). X. Local Mental Health Authority: Another term for a community mental health center (CMHC). Y. Mechanical restraint: The use of a mechanical device, material, or equipment attached or adjacent to the person’s body that they cannot easily remove that restricts freedom of movement or normal access to one’s body. Z. Medical Screening: Components of medical screening include patient’s personal information, doctor’s information (name, etc.), exam information, blood pressure, pulse, height, weight, current diagnosis, current medications, statement of freedom from communicable disease, physical and dietary limitations, and allergies. Must be signed by a licensed physician/nurse practitioner. AA. Mississippi Nurse Practice Act/Mississippi Board of Nursing: The Mississippi Nurse Practice Act is a set of laws which govern the practice of nursing in the State of Mississippi and outlines the scope of practice for certain categories of licensed nurses. The Mississippi Board of Nursing is the Mississippi state agency responsible for regulating the practice of nursing in Mississippi. Within this document, when nurses are referred to as performing in accordance with their applicable licensure entity, board, and/or scope of practice, they should do so in accordance with this act and with this board, as appropriate. BB. Peer: A self-identified person (or family member of a person) who has or is receiving mental health or substance use services. CC. Peer Support Service: Peer Support Services are non-clinical activities with a rehabilitation and resiliency/recovery focus that allow people receiving mental health services and substance use services and their family members the opportunity to build skills for coping with and managing psychiatric symptoms, substance use issues and challenges while directing their own recovery. Natural resources are utilized to enhance community living skills, community integration, rehabilitation, resiliency, and recovery. Peer Support is a helping relationship between peers and/or family member(s) that is directed toward the achievement of specific goals defined by the person. Peer Support Services are provided by a Certified Peer Support Specialist Professional. DD. Person-Centered Planning: A best practice approach to planning for people who require life-long supports and services. Person-Centered Planning discovers and acts on what is important to a person. Person-Centered principles are used to gather information with and from participants of the person’s choosing. The person and team develop individually tailored outcomes that are molded into activities to assist people in having meaningful days and in doing what they choose to do. EE. Person-Centered Recovery Oriented System of Care: Identification of the supports needed for individual recovery and resilience. Individualized and person-centered means that the combination of services and supports should respond to a person's needs, be self- directed, and should work with the strengths unique to each person's natural and community supports. Services and supports should be designed to help the person served identify and achieve their own recovery goals. This system of care is designed to recognize, respect, and accommodate differences relating to culture/ethnicity/race, religion, gender identity, and sexual orientation. An individualized/person-centered process also recognizes the importance of the family. FF. Physical intervention: Procedures used in conditions where the safety of the person with challenging behaviors, or others is in imminent danger. An evidence-based physical intervention training focuses on de-escalation skills and strategies first, with physical intervention used only as last resort. GG. Physical restraint: Any manual method, physical or mechanical device, or equipment that immobilized or reduces the ability of a person to move their arms, legs, or head freely when used as a restriction to manage a person’s behavior. Chapter 12 covers employees who are required to be trained and certified in a nationally recognized and DMH- approved technique for managing aggressive or risk-to-self behaviors to include verbal and physical de-escalation. DMH does not consider the proper implementation of this training by employees currently certified accordingly as being classified as use of physical restraint for the prevention or mitigation of harm to self or others. HH. Professional License: A license which is required by law and/or regulations to practice a certain profession or discipline. Professional licenses are typically governed by licensing/credentialing entities, which administer the professional licensing program and with promulgated scopes of practice. A professional license typically signifies that the license holder has met specific education, experience, and training requirements to obtain and maintain the license. Examples include Licensed Professional Counselor (LPC)/Provisional Licensed Professional Counselor (P-LPC), Licensed Psychologist, Licensed Master Social Worker (LMSW), Licensed Clinical Social Worker (LCSW), Licensed Marriage, and Family Therapist (LMFT), and Medical Doctor (MD). II. Psychiatric Services: Include interventions of a medical nature provided by medically trained personnel to address medical conditions related to the person’s mental illness or emotional disturbance. Medical services include medication evaluation and monitoring, nurse assessment, and medication injection. JJ. Recovery: A process of change through which people improve their health and wellness, live a self-directed life, and strive to reach their full potential. KK. Recovery-oriented services: Services that focus on peoples’ strengths, resources, skills, and assets to promote their wellbeing and build their confidence and resilience. Recovery-oriented services are dedicated to and organized around actively helping people served to achieve full personal recovery in their real life and service environment. LL. Relapse: A state of resuming any substance use, practices, or behaviors detrimental to the person’s quality of life, or a deterioration of a previous level of improvement. MM. Results-oriented: Services and supports that lead to improved outcomes for the person served. People have as much responsibility and self-sufficiency as possible, taking into consideration their age, goals, and personal circumstances. NN. Rural Setting: A Mississippi county that has a population of less than 50,000 people or an area that has fewer than 500 people per square mile or a municipality of fewer than 15,000 people (Data Source: Mississippi State Department of Health). OO. Seclusion: A behavior control technique involving locked isolation. Such term does not include a time-out. PP. Service location: A DMH-certified physical site (i.e., premises, building, or facility) where services/supports and/or programs are provided by the provider to people with SMI, SED, SUD, and/or IDD. QQ. Time-Out: A behavior management technique which involves temporarily removing a child/adolescent from social reinforcement into a non-locked room, for the purpose of calming. The time-out procedure must be part of an approved treatment service. The purpose of Time Out is to provide the child/adolescent the opportunity to calm down, regain self-control, and learn from their actions.