214-RICR-40-00-6. Mental Health Emergency Service Interventions for Children, Youth and Families Regulations for Certification (version Adoption, 09/18/2006 to 05/16/2012)

State of Rhode Island Department of Children, Youth and Families Mental Health Emergency Service Interventions for Children, Youth and Families Regulations for Certification September 18, 2006 Page 2 RI DCYF Mental Health Emergency Service Interventions for Children, Youth and Families – Regulations for Certification September 18, 2006 I. GENERAL PROVISIONS A. Purpose The purpose of these regulations is to comply with Rhode Island General Law (RIGL) 40.1-5-6, which requires any child who is under the age of eighteen (18) whose health insurance is publicly funded to have an emergency service intervention by a provider licensed by the Department of Children Youth and Families (DCYF) as a condition for admission to an inpatient psychiatric facility. These regulations set forth the standards for certifying providers and include standards for child-family competent clinicians. These regulations do not apply to emergency service interventions that result in emergency hospitalizations under RIGL 40.1-5-7, which provides that when an emergency hospitalization needs to occur, the preauthorization procedure required for authorization by the insurance company may be waived by the certified emergency service provider to protect the safety and well-being of the child and family. B. Legal Basis 1. These regulations are issued pursuant to: a. RIGL 42-72-5, Power and Scope of Activities of the Department of Children, Youth and Families b. RIGL 40.1-5-5. RIGL 40.1-5-6 and RIGL 40.1-5-8, Mental Health Law c. RIGL 42-72-5.2, Development of a Continuum of Children's Behavioral Health Programs d. RIGL 42-72.1-5, Licensing of Children’s Behavioral Health Programs 2. These regulations are consistent with the provisions of UR Regulations, R23-17.12 UR, Rules and Regulations for the Utilization Review of Health Care Services. 3. These regulations shall include children with SED as defined by RIGL 42-72-5. All providers certified to provide emergency services shall be licensed as children’s behavioral health programs pursuant to R.I.G.L. 42-72.1-5. C. Philosophy In accordance with RIGL 42-72-5, the Rhode Island Department of Children, Youth and Families is responsible for the delivery of appropriate mental health services that match the needs of children. Appropriate behavioral health services may include psychiatric hospitalization, residential treatment and Page 3 RI DCYF Mental Health Emergency Service Interventions for Children, Youth and Families – Regulations for Certification September 18, 2006 community-based mental health services, including emergency service interventions. In order to meet its responsibility, the Department has established a service delivery system based on Child and Adolescent Service System Program (CASSP) values to work with families with a child with severe emotional disturbance. It is the objective of DCYF to develop a service system that is youth guided and family driven, responsive to needs and built on strengths, culturally and linguistically competent and community based. These regulations further reinforce DCYF values by establishing standards for a child-family competent clinician who is providing emergency service interventions for children and families. These standards require that the clinician is knowledgeable of the full range of follow up services and resources. They include:  Community supports such as those provided through the Local Coordinating Councils  Community mental health services such as outpatient mental health, intensive outpatient and Children’s Intensive Services  In-home supports such as respite and crisis de-escalation  24-hour community-based programs such as shelters, respite, crisis stabilization and acute residential treatment  24-hour Inpatient Psychiatric hospitalization D. Definitions Child and Adolescent Service System Program (CASSP) – CASSP embodies core principles and values that are strength-based, child-centered and family- driven. CASSP involves a commitment to establishing and supporting a range of services for children and adolescents with serious emotional disturbances. The services are culturally and linguistically competent and emphasize natural and community-based supports that complement mental health services provided by professionals in agency and hospital settings. Child-Family Competency – Proficiency in clinical practice skills with children with severe emotional disturbance and their families, knowledge of research on child development, application of the knowledge in a clinical context and familiarity and experience with community resources in Rhode Island that benefit children and families, including knowledge of the cultural beliefs and practices of the diverse communities served. Child-Family Competent Clinician – A Registered Nurse, Masters Level Clinician, licensed Master’s Level Mental Health Clinician, M.D., Ph.D., Ed.D. or Psy.D. Psychologist, Master’s Level Nurse, or Clinical Nurse Specialist. The clinician must have at least two years of clinical experience with children and adolescents Page 4 RI DCYF Mental Health Emergency Service Interventions for Children, Youth and Families – Regulations for Certification September 18, 2006 who have behavioral health problems. This clinical experience must have been supervised by an independently licensed mental health clinician. The clinician must meet the standards of Child-Family Competency as described in the standards below. Each certified provider must determine the child-family competency of all staff providing children’s emergency services. Crisis Evaluation – A comprehensive assessment by a child-family competent clinician to evaluate the seriousness of the mental health crisis based on the child’s functioning and risk to self and others and the family/caregiver’s potential, skill level and capacity, with appropriate supports, to manage the behaviors that put the child at risk. Cultural and Linguistic Competency – The practice of behavioral health that includes the acceptance that severe emotional disorders and their causes vary by culture. There is acknowledgement that culture influences help-seeking behaviors and attitudes toward mental health providers/clinicians and the presence of diverse belief systems related to mental health and emotional well- being among cultures. A core competency is knowledge of the cultural beliefs and practices of a given group of people or community, including cultural differences in the definition of a mental health crisis, cultural norms for the process of de-escalating a crisis and crisis problem-solving. Linguistic competency includes:  Phone lines and web sites that assure access for people who are deaf or hearing impaired  Interpretation services available within the 120 minute time period for Emergency Services  Translated materials/forms for persons who do not speak or read English in the communities served by the Emergency Services Program DCYF Emergency Service Intervention Advisory Committee – A Committee, consisting of family members, DCYF staff, the Director of the Office of the Mental Health Advocate, representatives of the RiteCare Managed Care Organizations, the Rhode Island Department of Human Services (DHS), community mental health providers, hospital emergency room personnel and the certified emergency service intervention providers, that reviews compliance with these regulations through data and reports furnished by the Emergency Service Intervention Providers. The Assistant Director of DCYF for Community Services and Behavioral Health will chair the Committee. Emergency Service Intervention – A mental health crisis intervention that takes place in a community setting. The setting may include a school, police station, residential program, shelter, day care center, community mental health center, community health center, hospital emergency room or other community setting that the family and the child-family competent clinician agree is safe and clinically appropriate to resolve the mental health crisis. Page 5 RI DCYF Mental Health Emergency Service Interventions for Children, Youth and Families – Regulations for Certification September 18, 2006 Family Support Worker – A person who has first-hand family experience with mental health emergency service interventions as a parent, sibling or consumer and who is available to the family as part of the follow up service plan developed by the child-family competent clinician and the family. Follow up Service Plan – The resolution to the mental health crisis that is developed by the child-family competent clinician in partnership with the parent or legal guardian of the child. The plan considers the strengths of the family and child, considers all available community services and matches the services to the needs of the child and family. Mental Health Emergency – a situation perceived by a child, adolescent, caretaker, relative, friend, school professional, healthcare professional, police, or other public safety personnel in the care of, or directly involved with, a child or adolescent that poses a risk of harm to the child, family or other person due to a mental illness. Mental Health Emergency Service Interventions – Steps that are taken by a mental health provider to address a mental health crisis including telephone contact, crisis evaluation in the community and follow up service planning and implementation. Precertification – The process of obtaining approval from the third-party payer, which is required as a condition of payment for a specific benefit prior to the service being provided. In this policy the child-family competent clinician who is involved in the crisis evaluation will seek approval from the payer, when required by the RiteCare HMO, for the appropriate services that the family and clinician determine are a match for the mental health needs of the child. Psychiatric Hospital Admission Process – The process by which a child or adult may be admitted to an inpatient psychiatric hospital. The following types of admission are defined by RIGL 40.1-5-5 – 401-5-8.  Voluntary admission  Emergency certification  Civil court certification Utilization Review – Prospective, concurrent or retrospective assessment of the medical necessity and appropriateness of the allocation of health care services of a provider, given or proposed to be given to a patient or group of patients, as defined in Section 1.35 of UR Regulations cited above. Page 6 RI DCYF Mental Health Emergency Service Interventions for Children, Youth and Families – Regulations for Certification September 18, 2006 II. CERTIFICATION STANDARDS FOR MENTAL HEALTH EMERGENCY SERVICE INTERVENTIONS In order to be certified for emergency services, the provider must include a telephone crisis hotline, face-to-face interventions in the community and the means to develop and implement a follow up plan to access community-based and 24-hour services. The certified emergency service (ES) provider will meet the standards established under each component. A. Telephone Contact, Support and Follow up 1. The ES provider will establish a telephone system for families that will include the following: a. A phone line and a number which will be answered by a live voice 24 hours per day, seven days per week, 365 days per year. The answering service or provider must have the capacity to ensure access to the language of the caller. b. The caller will have telephone access to a child-family competent clinician within 15 minutes of the initial call to discuss the crisis and to develop a follow up service plan based on the family’s need and joint collaboration on next steps. c. The provider will track all phone calls, measure and report to DCYF on: i. The source of the call – parent, guardian, child or collateral party; ii. The percentage of calls answered within 15 minutes of the original request; iii. The percentage of calls that resulted in a face-to-face intervention. 2. The ES provider will work with DCYF, DHS and the RiteCare Health Maintenance Organizations (HMO) to publicize the service throughout their service delivery area including publicizing the services in languages other than English in diverse communities. B. Emergency Service Interventions - The ES provider will establish emergency service intervention policies and procedures that meet the following criteria: 1. Families, caregivers, health care professionals and others who are working with a child experiencing a mental health crisis will have access to a DCYF-certified Mental Health Emergency Service Intervention Team that consists of a child-family competent clinician with back-up from a clinical supervisor/administrator and a child- trained psychiatrist Monday through Friday from 9 a.m. to 9 p.m. except holidays. Between 9 p.m. and 9 a.m. on weekdays, and all Page 7 RI DCYF Mental Health Emergency Service Interventions for Children, Youth and Families – Regulations for Certification September 18, 2006 day on weekends and holidays, the psychiatrist on call must be licensed to practice medicine in Rhode Island and have at least two years experience with children or adolescents and two years in working with psychiatric emergencies. a. The clinician will provide face-to-face crisis counseling, evaluation of the current mental health emergency and the development of a follow up service plan for a family with a child experiencing a mental health crisis. b. The face-to-face contact will take place within 120 minutes of the family’s request regardless of the time of day of the call. c. The clinical supervisor and psychiatrist will be available to the clinician and collateral providers for telephone consultation on the assessment and case planning and will return pages or phone calls within 15 minutes of the request from the ES clinician. 2. The family and the clinician will jointly determine the location for the face-to-face crisis intervention to accommodate family needs and preferences, provide for the most timely and clinically appropriate setting to gather relevant information, increase the chances of de- escalating the crisis and protect the physical safety of all parties. 3. The child-family competent clinician will meet with the child and family and, as part of the intervention, will offer support, complete a crisis evaluation, assess the child and family for risk to harm self or others and engage the family and collateral providers in the assessment and follow up service planning process. 4. The ES provider will follow up with families to make sure that the follow up plan was implemented as planned. C. Follow up Service Planning - The ES provider will establish policies and procedures that include the following steps to complete the emergency service intervention with follow up service planning: 1. The child-family competent clinician will work with the family to resolve the mental health crisis to promote the health and safety of the child and the family by matching the services in the follow up plan to the strengths, needs, and preferences of the child and family. 2. The ES provider will be familiar with the full range of community, residential and hospital-based services that can best match the family’s needs and preferences. 3. The clinician will discuss the value of a Family Support Worker with the family and, if the family identifies the need for such support, make arrangements for a follow up face-to-face visit or telephone call to the family. Page 8 RI DCYF Mental Health Emergency Service Interventions for Children, Youth and Families – Regulations for Certification September 18, 2006 4. The ES provider will also be familiar with the procedures required to obtain access to these services based on clinical eligibility criteria and authorization procedures of the RiteCare HMO’s. 5. The child-family competent clinician will make an appropriate referral to a program and/or service based on the child-family assessment and mutually identified needs. The clinician and/or his/her organization will also complete any Precertification required by the insurer or managed care organization. The ES provider will ensure that the following steps occur in the follow up service planning process: a. The child-family competent clinician will discuss the follow up that the family prefers and will make arrangements to contact the family and/or the referral source the following day to make sure that the follow up resource was available. b. The ES Provider will have a form that notes the legal guardian’s signed agreement on the type of follow up in the encounter document or emergency evaluation that is part of the child’s medical record. c. The ES provider will be available to the child and family for follow up contact for 72 hours after the initial crisis intervention if other community resources are not immediately available. d. The ES provider will track any complaints from the family if and when they are unable access follow up services that are out of compliance with published access standards. e. The ES provider will establish a complaint and grievance procedure if the family disagrees with the follow up service plan. D. Standards for Child Family Competency 1. In order to be certified to provide emergency service interventions, the provider organization must establish a policy for the recruitment and/or training of emergency service staff. Staff must possess the following clinical skills: a. Child interview skills, including assessment of child’s coping skills, determining the locus of control and evaluating the risk of the child to harm him/herself or others based on intent, means and opportunity based on the developmental level and cognitive ability. b. Crisis de-escalation and diffusion of the behavioral health emergency, engaging both the child and the family in the intervention, gathering important information to make the best decision on follow-up care, partnering with the families on the follow-up plan and following up with the families to make sure the plan has been implemented as planned. Page 9 RI DCYF Mental Health Emergency Service Interventions for Children, Youth and Families – Regulations for Certification September 18, 2006 c. Family interview skills, including assessment of the family’s coping skills and their ability to manage crisis. d. The capacity to assess family supports and global risks based on the environment of supports and obstacles in which the family lives. e. The ability to incorporate family strengths and skills into the risk assessment and follow up plan. f. Skill in partnering with parents using family-centered language in planning follow-up services that match the needs of the child and family. g. Diagnostic formulation according to DSM IV-R criteria and child-specific risk criteria. h. Age appropriate crisis interventions that are designed to reduce immediate symptoms of behavioral health risk. i. Application of diagnostic formulation to determine the child’s behavior as a “severe emotional disturbance,” the immediate risk factors of the child’s potential to harm him/herself or others and the child’s and family’s strengths as factors in managing the crisis. j. Skill in applying differential interventions for families from diverse cultural, linguistic and ethnic backgrounds, ability to work effectively with interpreters, and clinical skills to provide interventions within a cultural context. 2. In order to be certified, the organization must confirm in writing that staff who provide child emergency service interventions possess the following knowledge: a. Age appropriate behavior, attitude and conceptualization b. Appropriate roles of parents with children based on age and behavior and culture c. Indications and side effects of psychiatric medications that are commonly prescribed for children and adolescents and how such medications are metabolized differently based on race, ethnicity, and age d. The full range of legal status categories of children involved with DCYF and the rights of children and families to consent to or refuse treatment e. The diverse cultures in Rhode Island, their family orientation and openness to sharing information, their attitude about children’s behavioral health and behavioral health and social service interventions, their experiences with and attitudes toward social services and culturally influenced definitions and perceptions of crisis f. The value of informal supports and extended family support as valid interventions Page 10 RI DCYF Mental Health Emergency Service Interventions for Children, Youth and Families – Regulations for Certification September 18, 2006 g. The value of matching services to the assessed needs of child and family based on the practical application of CASSP principles and values for a range of community-based services and in a range of cultural contexts. 3. In order to be certified as an ES provider, the organization must provide ongoing training, consultation, support and updated information to staff who provide emergency service interventions to children and families. There should be a minimum of 10 hours of training per year on current topics that relate to best practices and promising practices in children’s behavioral health and monthly updates on the changing network of managed care programs and community resources for children and families in Rhode Island. The updates will include: a. The types of RiteCare and Private Insurance, the behavioral health benefit packages and the behavioral health provider network of each insurance company. b. The eligibility and/or admission criteria for the children’s behavioral health treatment programs. c. A list of contact names and phone numbers for the community providers of children’s behavioral health treatment, advocacy, support and collateral services. 4. The provider will have an identified subject matter expert on the CASSP referral process and how to obtain access to social service, housing, employment and other Medicaid-funded services. 5. The ES provider will have knowledge of culture-specific services, the linguistic capacity of community services and the ability to work effectively with an interpreter (e.g. sign language and foreign language) 6. The organization will identify a clinical subject matter expert who can provide training and consultation to the emergency services staff based on his/her expertise on the current best practice interventions for children and families in the field of children’s behavioral health. E. Program Monitoring and Quality Improvement 1. The provider will collect encounter data on emergency service interventions and report to the DCYF Advisory Committee monthly. 2. The standardized report will include aggregate data of emergency service interventions that capture the age, gender, ethnicity, DCYF status, child’s living arrangement, insurance coverage, time of day, day of week, location of intervention and type of disposition. 3. The provider will develop an internal process to review complaints from the family or other parties involved in the intervention. Page 11 RI DCYF Mental Health Emergency Service Interventions for Children, Youth and Families – Regulations for Certification September 18, 2006 4. The provider will have a process, consistent with the DHS Fair Hearing process, of resolving disagreements with the family around the follow up service plan. F. The provider organization will be credentialed by and contracted with all Rite Care HMO’s and will be knowledgeable of the authorization procedures required to access services identified in the follow up service plan. G. The provider organization will have an established training protocol in children’s behavioral health that includes an annual plan to address the best practices and current findings related to working with children with severe emotional disturbances and their families from an individual and family systems, including cultural and linguistic perspectives. III. CERTIFICATION PROCESS FOR PROVIDERS OF EMERGENCY SERVICE INTERVENTIONS A. Application Process - Organizations applying to be certified to provide children’s emergency service interventions must complete an application for certification for mental health emergency interventions and submit to DCYF-Division of Community Services and Behavioral Health. The following information must be included with the application: 1. Documentation of contracts with the RiteCare HMO’s as a behavioral health provider. 2. Documentation of Certification by COA, JCAHO, CARF and/or MHRH. 3. Narrative answers that describe the organization’s delivery of children’s emergency service interventions that specifically address: a. Staffing of Child-Family competent clinicians; b. Twenty-four hour per day, seven day per week (24/7) live telephone coverage with administrative and child psychiatrist back-up; c. How the organization will determine child-family competency in recruitment, training and supervision of clinical staff; 4. A commitment to report to DCYF and the RiteCare HMO’s on monthly activity using the DCYF reporting format and a commitment to develop internal review mechanisms to monitor compliance with these standards. 5. A statement identifying the geographical areas the provider can reliably serve based on knowledge of and access to local mental health and community-based services and the provider’s ability to meet the timelines within these standards. Page 12 RI DCYF Mental Health Emergency Service Interventions for Children, Youth and Families – Regulations for Certification September 18, 2006 6. Elements of the agency’s quality improvement plan that relate to children’s behavioral health services. 7. A statement assuring compliance with DCYF Policy 900.0040, Criminal Record Checks and 700.0105, Clearance of Agency Activity. B. Applicant Eligibility 1. Any provider organization that provides behavioral health services to children and meets the criteria in 2 a, b or c below may apply to become an emergency services provider. 2. In compliance with the requirements of R.I.G.L. 42-72.1-5, DCYF will issue a temporary license as a children’s behavioral health provider if provider organization meets one of the following: a. Provider is licensed as a community mental health center by the Rhode Island Department of Mental Health, Retardation and Hospitals (MHRH). b. Provider is a certified Medicaid provider in Rhode Island and has one of the following: i. Current accreditation from the Joint Commission on Accreditation of Hospital Organizations (JCAHO) ii. Current certificate from the Commission on Accreditation of Rehabilitation Facilities (CARF) iii. Current certification from the Council on Accreditation (COA) of the Child Welfare League of America c. Provider is a certified Medicaid provider and is currently contracted in good standing with a RiteCare HMO or with DYCF for a specialty children’s behavioral health service. C. Approval Process 1. The DCYF Review Committee will review and make a recommendation regarding certification to the Assistant Director of DCYF for Community Services and Behavioral Health. The recommendation may be for full certification or provisional certification. The latter category will include conditions for full certification. 2. A provider whose application is not approved for certification may appeal to the Assistant Director of DCYF for Community Services and Behavioral Health no more than 30 days from the notice of the decision. IV. FUNDING FOR CHILDREN WITHOUT HEALTH INSURANCE COVERAGE Page 13 RI DCYF Mental Health Emergency Service Interventions for Children, Youth and Families – Regulations for Certification September 18, 2006 DCYF will designate a small pool of funds for families who do not have insurance and will reimburse the provider for mental health emergency service interventions provided to those families at the same rate as DCYF funded fee-for-service Medicaid. Bills submitted to DCYF for these services will include an assurance that all attempts to verify insurance have been made and that the family agreed to apply for Medicaid if qualified, and that the family did not have the means to contribute to the cost of the evaluation. V. DURATION OF CERTIFICATION DCYF will certify a provider for two years from the approval date with an annual renewal based on satisfactory compliance with the certification standards.