Section
3.10 SMI Eligibility Determination
3.10.1
Introduction
3.10.2 References
3.10.3 Scope
3.10.4 Definitions
3.10.5 Objectives
3.10.6 Procedures
3.10.6-A: General requirements
3.10.6-B: Criteria for SMI eligibility determination
3.10.6-C: Process for completion of SMI eligibility
determination
3.10.6-D: Issues preventing timely completion
of SMI eligibility determination
3.10.6-E: Notification of SMI eligibility
determination
3.10.6-F: Review of SMI eligibility determination
3.10.1 Introduction
A critical focus of the ADHS/DBHS service delivery system is the
effective and efficient delivery of behavioral health services to
persons who have special needs due to the serious nature of their
behavioral health disorder. One such group is persons with serious
mental illness (SMI). Without receipt of appropriate care, these
persons are at high risk for further deterioration of their physical
and mental condition, increased hospitalizations and potential homelessness
and incarceration.
In order to
ensure that persons with serious mental illness are provided the
necessary behavioral health services, ADHS/DBHS has developed a
standardized process by which T/RBHAs and their providers may readily
identify persons with serious mental illness and promptly enroll
them into the ADHS/DBHS behavioral health system. The requirements
associated with making an SMI determination are set forth in this
section.
3.10.2
References
The following citations can serve as additional resources for this
content area:
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3.10.3
Scope
To whom does this apply?
- Persons
who are referred for, request or have been determined to need
an eligibility determination for serious mental illness; or
- Persons who
have been determined to be seriously mentally ill and are enrolled
in the ADHS/DBHS behavioral health system.
3.10.4
Definitions
Serious
mental illness (SMI)
3.10.5
Objectives
The objective of this section is to ensure the prompt and accurate
identification of persons with serious mental illness.
3.10.6
Procedures
3.10.6-A.
General requirements
The Gila River Regional Behavioral Health Authority (RBHA) is responsible
for identifying and conducting an SMI determination for persons
who may have a serious mental illness. All persons must be evaluated
by, or have their records reviewed by, a licensed psychiatrist,
psychologist, or nurse practitioner designated by the T/RBHA for
determination of SMI, if the person:
- Requests
an SMI determination; or
- Has a score
of 50 or lower on the Global Assessment of Functioning Scale (GAF)
and has a qualifying SMI diagnosis (see PM
Attachment 3.10.1 for a list of qualifying diagnoses).
Behavioral health
providers must use the GAF as a screen for identifying persons (including
enrolled children upon reaching 17 years of age) who may have functional
impairments indicative of a serious mental illness. The GAF is completed
as part of the assessment process (see Section
3.9, Intake, Assessment and Service Planning).
All Title XIX
and Title XXI eligible persons must receive all necessary Title
XIX or Title XXI covered services, including case management, throughout
the SMI eligibility determination process.
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3.10.6-B.
Criteria for SMI eligibility determination
The determination of SMI requires both a qualifying SMI diagnosis
and functional impairment as a result of the qualifying diagnosis
(see PM
Attachment 3.10.1 for a list of qualifying diagnoses).
Functional
Criteria for SMI Determination
To meet the functional criteria for SMI, a person must have, as
a result of a qualifying SMI diagnosis, dysfunction in at least
one of the following four domains, as described below, for most
of the past twelve months or for most of the past six months with
an expected continued duration of at least six months:
- Inability
to live in an independent or family setting without supervision
– Neglect or disruption of ability to attend to basic needs.
Needs assistance in caring for self. Unable to care for self in
safe or sanitary manner. Housing, food and clothing, must be provided
or arranged for by others. Unable to attend to the majority of
basic needs of hygiene, grooming, nutrition, medical and dental
care. Unwilling to seek prenatal care or necessary medical/dental
care for serious medical or dental conditions. Refuses treatment
for life threatening illnesses because of behavioral health disorder.
- A risk of
serious harm to self or others – Seriously disruptive to
family and/or community. Pervasively or imminently dangerous to
self or others’ bodily safety. Regularly engages in assaultive
behavior. Has been arrested, incarcerated, hospitalized or at
risk of confinement because of dangerous behavior. Persistently
neglectful or abusive towards others in the person’s care.
Severe disruption of daily life due to frequent thoughts of death,
suicide, or self-harm, often with behavioral intent and/or plan.
Affective disruption causes significant damage to the person’s
education, livelihood, career, or personal relationships.
- Dysfunction
in role performance – Frequently disruptive or in trouble
at work or at school. Frequently terminated from work or suspended/expelled
from school. Major disruption of role functioning. Requires structured
or supervised work or school setting. Performance significantly
below expectation for cognitive/developmental level. Unable to
work, attend school, or meet other developmentally appropriate
responsibilities; or
- Risk of Deterioration
– A qualifying diagnosis with probable chronic, relapsing
and remitting course. Co-morbidities (like mental retardation,
substance dependence, personality disorders, etc.). Persistent
or chronic factors such as social isolation, poverty, extreme
chronic stressors (life-threatening or debilitating medical illnesses,
victimization, etc.). Other (past psychiatric history; gains in
functioning have not solidified or are a result of current compliance
only; court-committed; care is complicated and requires multiple
providers; etc.).
The following
reasons shall not be sufficient in and of themselves for denial
of SMI eligibility:
- An inability
to obtain existing records or information; or
- Lack of
a face-to-face psychiatric or psychological evaluation.
Person with
Co-occurring Substance Abuse
For persons with co-occurring substance abuse without an established
psychiatric diagnosis, the diagnostic assessment may be performed
in accordance with the Co-occurring
Psychiatric And Substance Disorders Practice Improvement Protocol.
For persons
who have a qualifying SMI diagnosis and co-occurring substance abuse,
for purposes of SMI determination, presumption of functional impairment
is as follows:
- For psychotic
diagnoses (bipolar I disorder with psychotic features, delusional
disorder, major depression, recurrent, severe, with psychotic
features, schizophrenia, schizoaffective disorder and psychotic
disorder NOS) functional impairment is presumed to be due to the
qualifying psychiatric diagnosis;
- For other
major mental disorders (bipolar disorders, major depression and
obsessive compulsive disorder), functional impairment is presumed
to be due to the psychiatric diagnosis, unless:
- The
severity, frequency, duration or characteristics of symptoms
contributing to the functional impairment cannot be attributed
to the qualifying mental health diagnosis, or;
- The assessor
can demonstrate, based on a historical or prospective period
of treatment, that the functional impairment is present only
when the person is abusing substances or experiencing symptoms
of withdrawal from substances.
- For all other
mental disorders not covered above, functional impairment is presumed
to be due to the co-occurring substance use unless:
- The
symptoms contributing to the functional impairment cannot
be attributed to the substance abuse disorder (see PM
Attachment 3.10.2, Substance Use/Psychiatric Symptomatology
Table (Note 1)); or
- The
functional impairment is present during a period of cessation
of the co-occurring substance use of at least 30 days; or
- The
functional impairment is present during a period of reduced
use unlikely to cause the symptoms or level of dysfunction
of at least 90 days.
Re-enrollment
or Transfer
If the person’s status is SMI at disenrollment or upon transfer
from another T/RBHA, the person’s status shall continue as
SMI upon re-enrollment or transfer.
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3.10.6-C.
Process for completion of SMI eligibility determination
Upon receipt of a referral for, a request, or identification of
the need for an SMI determination, the Gila River RBHA shall schedule
an appointment for an initial meeting with the person and a qualified
assessor (see Section
3.20, Credentialing and Privileging). This shall occur
no later than 7 days after receiving the request or referral.
During the initial
meeting with the person by a qualified assessor, the assessor must:
- Make a clinical
assessment whether the person is competent enough to participate
in an assessment;
- Obtain general
consent from the person or, if applicable, the person’s
guardian to conduct an assessment;
- Provide to
the person and, if applicable, the person’s guardian, the
information required in R9-21-301(D)(2), a client rights brochure,
and the appeal notice required by R9-21-401(B); and
- If, during
the initial meeting with the person, the assessor is unable to
obtain sufficient information to determine whether the applicant
is SMI, the assessor must:
- Request
the additional information in order to make a determination
of whether the person is SMI and obtain an authorization for
the release of information, if applicable (see Section
4.1, Disclosure of Behavioral Health Information);
and
- Initiate
an assessment including completion of the Serious Mentally
Ill Determination Addendum (see PM
Form 3.9.1) that is part of the standardized
ADHS/DBHS assessment tool.
The licensed
psychiatrist, psychologist, or nurse practitioner designated by
the T/RBHA must make a final determination as to whether the person
meets the eligibility requirements for SMI status based on:
- Conducting
a face-to-face assessment or reviewing a face-to-face assessment
by a qualified assessor (see Section
3.20, Credentialing and Privileging); and
- A review
of current and historical information, if any, obtained orally
or in writing by the assessor from collateral sources, and/or
present or previous treating clinicians.
If the designated
reviewing psychiatrist, psychologist, or nurse practitioner has
not conducted a face-to-face assessment and has a disagreement with:
- The current
evaluating or treating qualified behavioral health professional
or behavioral health technician regarding the diagnosis that cannot
be resolved by oral or written communication, determination that
the person does not meet eligibility requirements for SMI status
must be based on a face to face diagnostic evaluation conducted
by a designated psychiatrist, psychologist, or nurse practitioner.
The resolution of (specific reasons for) the disagreement shall
be documented in the person’s comprehensive clinical record.
- The current
evaluating or treating qualified behavioral health professional
or behavioral health technician regarding functional impairment
that will result in a determination that the person does not meet
eligibility requirements for SMI status that cannot be resolved
by oral or written communications. Determination that the person
does not meet eligibility requirements must be based upon a face-to-face
functional evaluation conducted by a designated psychiatrist,
psychologist, or nurse practitioner. The psychiatrist, psychologist,
or nurse practitioner shall document the specific reason(s) for
the disagreement in the person’s comprehensive clinical
record.
If there is
sufficient information to determine SMI status, the person shall
be provided written notice of the SMI eligibility determination
within three business days of the initial meeting with the qualified
assessor in accordance with Subsection 3.10.6-E. below.
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3.10.6-D.
Issues preventing timely completion of SMI eligibility determination
The time to initiate or complete the SMI eligibility determination
may be extended no more than 20 days if the person agrees to the
extension and:
- There is
substantial difficulty in scheduling a meeting at which all necessary
participants can attend;
- The person
fails to keep an appointment for assessment, evaluation or any
other necessary meeting (see Section
3.8, Outreach, Engagement, Re-engagement, Closure and Re-enrollment);
- The person
is capable of, but temporarily refuses to cooperate in the preparation
of the completion of an assessment or evaluation;
- The person
or the person’s guardian and/or designated representative
requests an extension of time;
- Additional
documentation has been requested, but has not yet been received;
or
- There is
insufficient functional or diagnostic information (Note
2) to determine SMI eligibility within the required time periods.
The T/RBHA or
their designee must:
- Document
the reasons for the delay in the person’s comprehensive
clinical record when there is an administrative or other emergency
that will delay the determination of SMI status; and
- Not use the
delay as a waiting period before determining SMI status or as
a reason for determining that the person does not meet the criteria
for SMI eligibility (because the determination was not made within
the time standards).
In situations
in which the extension is due to insufficient information:
- The T/RBHA
or responsible provider shall request and obtain the additional
documentation needed (e.g., current and/or past medical records)
and/or perform or obtain any necessary psychiatric or psychological
evaluations;
- The designated
reviewing psychiatrist, psychologist, or nurse practitioner must
communicate with the person’s current treating practitioner,
if any, prior to the determination of SMI, if there is insufficient
information to determine the person’s level of functioning;
an
- SMI eligibility
must be determined within three days of obtaining sufficient information.
If the person
refuses to grant an extension, SMI eligibility must be determined
based on the available information. If SMI eligibility is denied,
the person will be notified of his/her appeal rights and the option
to reapply (see subsection 3.10.6-E. below).
If the evaluation
or information cannot be obtained within the required time period
because of the need for a period of observation or abstinence from
substance use in order to establish a qualifying mental health diagnosis,
(in accordance with PM
Attachment 3.10.2, Substance Use/Psychiatric Symptomatology Table),
the person shall be notified that the determination may, with the
agreement of the person, be extended for up to 90 (calendar) days
(Note 3).
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3.10.6-E.
Notification of SMI eligibility determination
A determination of SMI status must be reported to the person in
writing, including notice of his/her right to appeal the decision
(see Section 5.5,
Notice and Appeal Requirements (SMI and Non-SMI/Non-Title XIX/XXI).
If the eligibility
determination results in a denial of SMI status, the T/RBHA shall
notify the person in writing of:
3.10.6-F.
Review of SMI eligibility determination
The T/RBHA or a behavioral health provider may:
- Institute
a periodic review of all persons determined to have a serious
mental illness; and
- Re-evaluate
in three to six months a person’s SMI status if the person
has a qualifying diagnosis and has met the functional criteria
for risk of serious harm to self or others.
If as a result
of such review, the person is determined to no longer meet the diagnosis
and functional requirements for SMI status, the T/RBHA must ensure
that:
- Services
are continued depending on Title XIX/XXI eligibility, T/RBHA service
priorities and any other requirements described in Section
3.21, Service Prioritization for Non-Title XIX/XXI Funding.
- Written
notice of the reason for adverse determination and the right to
appeal are provided to the affected person (see subsection 3.10.6-E
above).
NOTES:
(1) The psychiatric symptomatology table is a guideline
only and is not to be used as a substitute for professional clinical
judgment.
(2) Insufficient diagnostic information shall be understood to mean
that the information available to the reviewer is suggestive of
two or more equally likely working diagnoses, only one of which
qualifies as SMI, and an additional piece of existing historical
information or a face-to-face psychiatric evaluation is likely to
support one diagnosis more than the other(s).
(3) This extension may be considered a technical re-application
to ensure compliance with the intent of Rule. However, the person
does not need to actually reapply. Alternatively, the determination
process may be suspended and a new application initiated upon receipt
of necessary information.
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3.10
SMI Eligibility Determination
Last Revised: 09/09/2004
Effective Date: 07/01/2005
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