Section
3.17 Transition of Persons
3.17.1
Introduction
3.17.2 References
3.17.3 Scope
3.17.4 Did you know…?
3.17.5 Objectives
3.17.6 Definitions
3.17.7 Procedures
3.17.7-A. Transition from child to adult
services
3.17.7-B. Transition due to a change of the clinical
liaison, a provider or the behavioral health category assignment
3.17.7-C. Transition to ALTCS Program Contractors
3.17.7-D. Inter-T/RBHA Transfer
3.17.7-E. Transitions of persons receiving court
ordered services
3.17.1
Introduction
Persons receiving behavioral health services in the ADHS/DBHS system
may experience transitions during the course of their care and treatment.
Examples of transitions of care include changing service providers,
establishing eligibility under Arizona Long Term Care Services (ALTCS),
transitioning into adulthood, and moving out of the T/RBHA’s
geographic service area. During transitions of care, behavioral
health providers must ensure that services are not interrupted and
that the person continues to receive needed behavioral health services.
Coordination and continuity of care during transitions are essential
in maintaining a person’s stability and avoiding relapse or
decompensation in functioning.
The intent of
this section is to:
- Identify
the situations that require a transition of care;
- Describe
expectations for providers when initiating or accepting a transition
of care for an enrolled person; and
- Identify
resources to assist behavioral health providers in supporting
a person who is experiencing a transition of care.
3.17.2
References
The following citations can serve as additional resources
for this content area:
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3.17.3
Scope
To whom does this apply?
All persons
currently enrolled with a T/RBHA and experiencing a transition of
care.
3.17.4
Did you know?
- Some persons
may experience a transition of payers, but not actually change
providers. This could happen, for example, when a Title XIX behavioral
health recipient moves from an AHCCCS acute care Health Plan to
the ALTCS program. Many ALTCS Program Contractors for the elderly
and physically disabled (ALTCS/EPD) contract with the same behavioral
health providers as the T/RBHAs. This kind of transition, where
fiscal responsibility changes but not the provider, may be transparent
to the person receiving services, but could result in administrative
changes for the provider (e.g., submitting claims or bills to
the ALTCS Program Contractor versus submitting an encounter as
a T/RBHA provider).
- The ALTCS
program is considered a “carve-in model,” a service
delivery model that assigns coverage of medical and behavioral
health services through a single entity (i.e., Program Contractor).
An exception to this “carve-in model” is the delivery
of covered behavioral health services for persons eligible for
ALTCS through the Division of Developmental Disabilities (DDD).
ALTCS/DDD eligible persons receive covered behavioral health services
through the RBHAs and their subcontracted behavioral health providers.
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3.17.5
Objectives
To ensure the coordination and continuity of care for persons experiencing
a transition in service providers.
3.17.6
Definitions
Behavioral
Health Category Assignment
Clinical
Liaison
Designated
T/RBHA
Home
T/RBHA
Independent
Living Setting
Institution
for Mental Disease (IMD)
Out-of-area
service
Residence
Serious
Mental Illness (SMI)
Transfer
3.17.7
Procedures
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3.17.7-A.
Transition from child to adult services
When a child who has been involved in long term or intensive
behavioral health care reaches the age of 16, planning for the transition
into the adult behavioral health system must begin. A transition
plan that starts with an assessment of self-care and independent
living skills, social skills, work and education plans, earning
potential and psychiatric stability must be incorporated in the
child’s individual service plan.
What elements
should be addressed as part of the child’s transition plan?
Some of the elements to be addressed by the Child and Family Team
and/or Clinical Liaison as part of a transition plan include:
- What are
likely to be the child’s behavioral health needs into adulthood?
- What personal
strengths will assist the child when he/she transitions to the
adult system?
- Will there
be a change in provider, the clinical team, family involvement,
and/or the clinical liaison? How will the transition be implemented?
- Where will
the child reside upon turning 18 and how will he/she support him/herself?
- Will the
child need referrals to and assistance with applications for Supplemental
Security Income (SSI), Rehabilitation Services Administration
(RSA), Serious Mental Illness (SMI) eligibility determination,
Title XIX and Title XXI eligibility, housing, guardianship, training
programs, etc.? Are there medical and school records to substantiate
these needs? Begin to gather necessary information to expedite
these applications/determinations when the time comes to actually
apply. Develop a timeline and task list for when appointments
are needed.
- Will the
child have or need transportation to appointments and other necessary
activities?
- Does the
child have special needs or will the child require special assistance
services?
- Does the
child have appropriate life skills, social skills and employment
or education plans?
- What actions
need to be taken if the child is not eligible for Title XIX or
Title XXI benefits and/or Social Security Disability Income (SSDI)
and is not determined to have a serious mental illness?
- What supports
need to be in place for a successful transition?
- If an SMI
eligibility determination is made, consider initiating a referral
for housing, if needed.
What needs
to happen during the year before the child transitions to adult
services?
- When a child
receiving behavioral health services reaches the age of 17, behavioral
health providers must determine whether the child is potentially
eligible for services as an adult with a serious mental illness.
If so, behavioral health providers must refer the child for an
SMI eligibility determination pursuant to Section
3.10, SMI Eligibility Determination.
- When a child
receiving behavioral health services reaches 17 and a half, the
Child and Family Team and/or the clinical liaison must:
- Assist
the child and/or family or guardian in applying for potential
benefits (e.g., SSI, food stamps, etc.);
- Assist
the child and/or family in applying for Title XIX or Title
XXI benefits; if the child and/or family is already eligible,
determine if eligibility will continue for the child once
he/she turns 18;
- Address
any new authorization requirements for sharing protected health
information due to the child turning 18 (as described in Section
4.1, Disclosure of Behavioral Health Information)
to ensure that the clinical team can continue to share information;
- Ensure
that the child’s behavioral health category assignment
is changed consistent with Section 7.5, Enrollment, Disenrollment
and other Data Submission. Once the child’s behavioral
health category assignment has been changed, ongoing behavioral
health service appointments must be provided according to
the timeframes for routine appointments in Section
3.2, Appointment Standards and Timeliness of Services;
and
- Upon
turning 18 years of age, if the person is not eligible for
services as a person determined to have a serious mental illness
or the person has been determined ineligible for Title XIX
or Title XXI services, behavioral health providers can continue
to provide behavioral health services consistent with Section
3.21, Service Prioritization for Non-Title XIX/XXI Funding
and Section 3.4, Co-payments.
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3.17.7-B:
Transition due to a change of the clinical liaison, a provider or
the behavioral health category assignment
Upon changes of a person’s clinical liaison, provider or behavioral
health category assignment, the clinical liaison must:
- Review the
current individual service plan and, if needed, coordinate the
development of a revised individual service plan with the person,
clinical team and the receiving clinical liaison;
- Ensure that
the person’s comprehensive clinical record is transitioned
to the receiving clinical liaison;
- Ensure the
transfer of responsibility for court ordered treatment, if applicable;
and
- Coordinate
the transfer of any other relevant information between clinical
liaisons and provider agencies, if needed.
The assigned
Gila River RBHA Clinician acts in the capacity of clinical liaison
for all RBHA enrolled persons. Prior to the assignment of a RBHA
Clinician, the RBHA staff person who completes the initial assessment
serves as the person’s clinical liaison.
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3.17.7-C:
Transition to ALTCS Program Contractors
This section does not apply to persons enrolled in the
Arizona Long Term Care Services/Division of Developmental Disabilities
(ALTCS/DDD). ALTCS/DDD eligible persons receive all covered behavioral
health services through T/RBHAs and their contracted providers.
Once a person
is determined eligible and becomes enrolled with the Arizona Long
Term Care Services/Elderly or Physically Disabled (ALTCS/EPD) Program,
behavioral health providers must not submit claims or encounters
for Title XIX covered services to the T/RBHA. To determine if a
person is ALTCS/EPD eligible, call (602) 528-7141. The behavioral
health provider must, however, continue to provide and encounter
needed non-Title XIX covered SMI services (e.g. housing) to persons
determined to have a serious mental illness.
Behavioral health
providers who contract as an ALTCS provider must not submit encounters
for an ALTCS/EPD enrolled person to the RBHA after a person transfers
to ALTCS, but must submit bills/claims for payment to the ALTCS
Program Contractor who in turn submits the encounters to AHCCCS.
When a person
who has been receiving behavioral health services through the T/RBHA
becomes enrolled in the ALTCS Program, the clinical liaison must:
- Include
the member in transition planning and provide any available information
about changes in physician, services, etc.;
- Ensure that
the clinical and fiscal responsibility for Title XIX behavioral
health services shifts to the ALTCS Program Contractor;
- Provide information
to the ALTCS Program Contractor regarding the person’s on-going
needs for behavioral health services to ensure continuity of care
during the transition period;
- Review the
current treatment plan and, if needed, coordinate the development
of a revised treatment plan with the clinical team and the receiving
ALTCS provider and/or case manager;
- Transfer
responsibility for any court ordered treatment;
- Coordinate
the transfer of records to the ALTCS program contractor; and
- Provide
information as follows:
- For
Title XIX eligible 21-64 year olds, the number of days the
person has received services in an Institution for Mental
Disease (IMD) in the contract year (July 1 – June 30)
- For
all persons, the number of hours of respite received in the
contract year (July 1 – June 30); and
- Whether
there is a signed authorization for the release of information
contained in the comprehensive behavioral health record pursuant
to Section 4.1, Disclosure
of Behavioral Health Information.
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3.17.7-D
Inter-T/RBHA Transfer
How is T/RBHA responsibility determined for adults? For adults (persons
18 years and older), T/RBHA responsibility is determined by the
adult person’s current place of residence, except in the following
situation:
- Persons
who are unable to live independently must not be transferred to
another T/RBHA with the exception of persons who are unable to
live independently but are involved with the Division of Developmental
Disabilities. Persons involved with DDD who reside in a supervised
setting are the responsibility of the T/RBHA in which the supervised
setting is located. This is true regardless of where the adult
guardian lives.
How is T/RBHA
responsibility determined for children?
- For children
(ages 0-17 years), T/RBHA responsibility is determined by the
current place of residence of the child’s parent(s) or legal
guardian; and
- For children
who have been adjudicated as dependent by a court, the location
of the child’s court of jurisdiction determines which T/RBHA
has responsibility.
How is T/RBHA
responsibility determined for persons who are temporarily residing
in another T/RBHA’s geographic service area?
The home T/RBHA remains fiscally responsible for all services provided
to an enrolled person who is visiting or otherwise temporarily residing
in a different T/RBHA’s geographic service area as long as
the person, or legal guardian for a child, maintains a place of
residence in the home T/RBHA’s geographic service area and
intends to return. If the person, or legal guardian for a child,
continues to reside in the new location after 3 months, the provider
or T/RBHA may proceed with an Inter-T/RBHA transfer if the person,
or legal guardian for a child, is consulted and agrees to the change.
Only persons who are able to live independently, with the exception
of persons who are unable to live independently but are involved
with the Division of Developmental Disabilities (DDD), can be transferred.
Crisis services
must be provided without regard to the person’s enrollment
status. When a person presents for crisis services, the T/RBHA or
their contracted providers must:
- Provide
needed crisis services;
- Ascertain
the person’s enrollment status with all T/RBHAs and determine
whether the person’s residence in the current area is temporary
or permanent.
If the person
is enrolled with another T/RBHA, notify the home T/RBHA within 24
hours of the person’s presentation. The home T/RBHA or their
contracted providers is fiscally responsible for crisis services
and must:
- Make arrangements
with the T/RBHA at which the person presents to provide needed
services, funded by the home T/RBHA;
- Arrange transportation
to return the person to the home T/RBHA area; or
- Determine
if the person intends to live in the new T/RBHA’s geographic
service area and if so, initiate a transfer.
If the person
is not enrolled with any T/RBHA and lives within the service area
of the T/RBHA in which the person presented for services, behavioral
health providers must notify the T/RBHA to initiate an enrollment.
Provider requests to initiate an enrollment with the Gila River
RBHA may be made by calling (602) 528-7100.
If the person
is not enrolled with a T/RBHA, lives outside of the service area
in which he/she presents and requires services other than a crisis
or urgent response to a hospital, the T/RBHA or their contracted
providers must notify the designated T/RBHA associated with the
person’s residence within 24 hours of the person’s presentation.
The designated T/RBHA must proceed with the person’s enrollment
if the person is determined eligible for services. The designated
T/RBHA is fiscally responsible for the provision of all medically
necessary covered services, including transportation services, for
eligible persons.
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What if
a T/RBHA or provider receives a referral for a hospitalized person?
In the event that a T/RBHA or provider receives a referral regarding
a hospitalized person whose residence is located outside the T/RBHA’s
geographic service area, the T/RBHA or provider must immediately
coordinate the referral with the person’s designated T/RBHA.
When is
an Inter-T/RBHA Transfer required?
- An Inter-T/RBHA
transfer must be completed when: An adult person voluntarily elects
to change his/her place of residence to an independent living
setting from one T/RBHA’s area to another. Only adult persons
who are able to live independently can be transferred to another
T/RBHA, with the exception of persons who are unable to live independently
but are involved with DDD. Adult persons involved with DDD who
reside in a supervised setting are the responsibility of the T/RBHA
in which the supervised setting is located;
- DDD transfers
an adult person who is unable to live independently, but involved
with DDD, to another placement;
- The parent(s)
or legal guardian(s) of a child change their place of residence
to another T/RBHA’s area; or
- The court
of jurisdiction of a dependent child changes to another T/RBHA’s
area.
What are
the timeframes for initiating an Inter-T/RBHA transfer?
The home T/RBHA or its contracted providers must initiate a referral
for an Inter-T/RBHA transfer within the following timeframes:
At least 30 days prior to the date on which the person will move
to the new area; or
If the planned
move is in less than 30 days, immediately upon learning of the person’s
intent to move.
What are
the responsibilities of the receiving T/RBHA during an Inter-T/RBHA
transfer?
Within 14 days of receipt of the referral for an Inter-T/RBHA transfer,
the receiving T/RBHA or its subcontracted providers must:
- Schedule
a meeting to establish a transition plan for the person. The meeting
must include:
- The
person or the person’s guardian or parent, if applicable;
- Representatives
from the home T/RBHA;
- Representatives
from the Arizona State Hospital, when applicable;
- The Clinical
Liaison and representatives of the child and family team/adult
clinical team;
- Other
involved agencies; and
- Any other
relevant participant at the person’s request or with
the consent of the person’s guardian.
- Establish
a transition plan that includes at least the following:
- The
person’s projected moving date and place of residence;
- Treatment
and support services needed by the person and the timeframe
within which the services are needed;
- A determination
of the need to request a change of venue for court ordered
treatment and who is responsible for making the request to
the court, if applicable;
- Information
to be provided to the person regarding how to access services
immediately upon relocation;
- The
enrollment date, time and place at the receiving T/RBHA and
the formal date of transfer, if different from the enrollment
date;
- The date
and location of the person’s first service appointment
in the receiving T/RBHA’s geographic service area;
- The
individual responsible for coordinating any needed change
of health plan enrollment, primary care provider assignment
and medication coverage;
- The person’s
Clinical Liaison in the receiving T/RBHA’s geographic
service area, including information on how to contact the
Clinical Liaison;
- Identification
of the person at the receiving T/RBHA who is responsible for
coordination of the transfer, if other than the person’s
Clinical Liaison;
- Identification
of any special authorization required for any recommended
service (e.g., non-formulary medications) and the individual
who is responsible for obtaining needed authorizations; and
- If the
person is taking medications prescribed for the person’s
behavioral health issue, the location and date of the person’s
first appointment with a practitioner who can prescribe medications.
There must not be a gap in the availability of prescribed
medications to the person.
Who is responsible
for initiating an Inter-T/RBHA transfer?
The person’s assigned Gila River RBHA Clinician/clinical liaison
is responsible for initiating Inter-T/RBHA transfers. The Gila River
RBHA Clinical Manager or designee is responsible for overall coordination
with the referring or receiving RBHA to ensure uninterrupted care
to the member.
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What are
the Clinical Liaison’s responsibilities during an Inter-T/RBHA
transfer?
As part of an Inter-T/RBHA transfer, the clinical liaison must:
- Include
the person in transition planning and provide any available information
about changes in physician, services, etc.;
- Provide
information regarding the person’s on-going needs for behavioral
health services to ensure continuity of care during the transition
period;
- Review the
current treatment plan and, if needed, coordinate the development
of a revised treatment plan with the clinical team and the receiving
provider;
- Transfer
responsibility for any court ordered treatment;
- Coordinate
the transfer of records to the new clinical liaison; and
- Provide
information as follows:
- For
Title XIX eligible 21-64 year olds, the number of days the
person has received services in an Institution for Mental
Disease (IMD) in the contract year (July 1 – June 30);
- For
all persons, the number of hours of respite received in the
contract year (July 1 – June 30); and
- Any signed
authorizations for the release of information contained in the
person’s comprehensive clinical record pursuant to Section
4.1, Disclosure of Behavioral Health Information.
What are
the timeframes for completing an Inter-T/RBHA transfer?
When an Inter-T/RBHA transfer occurs, the person must be disenrolled
from the home T/RBHA and enrolled in the receiving T/RBHA contingent
upon the date the person expects to relocate to the receiving T/RBHA’s
geographic service area, but no later than 30 days of the referral
by the home T/RBHA (see Section 7.5, Enrollment, Disenrollment and
Other Data Submission). This timeframe allows sufficient time for
the receiving T/RBHA to arrange for services and plan the person’s
transition.
Who is responsible
for care during an Inter-T/RBHA transfer?
In an Inter-T/RBHA transfer, the home T/RBHA and its contracted
providers retain responsibility for service provision and coordination
of care until such time as a person’s record is closed for
that T/RBHA (see Section 3.8, Outreach,
Engagement, Re-engagement and Closure). The receiving
T/RBHA must not delay the timely processing of an Inter-T/RBHA transfer
because of missing or incomplete information.
Courtesy
Dosing of Methadone
A person receiving methadone administration services who is not
a recipient of take-home medication may receive up to two courtesy
doses of methadone from a T/RBHA or its contracted providers while
the person is traveling outside of the home T/RBHA area. All incidents
of provision of courtesy dosing shall be reported to the home T/RBHA.
The home T/RBHA shall reimburse the behavioral health provider providing
the courtesy doses upon receipt of properly submitted bills or encounters.
Appeals
for Out-of-Area Service Provision
Persons determined to have a serious mental illness who are the
subject of a request for out-of-area service provision or Inter-T/RBHA
transfer may file an appeal in accordance with Section
5.5, Notice and Appeal Requirements (SMI and Non-SMI/Non-Title XIX/XXI).
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3.17.7-E.
Transitions of persons receiving court ordered services
This section pertains to court ordered treatment under A.R.S.
§ 36, Chapter 5 (see Section
3.18, Pre-petition Screening, Court Ordered Evaluation and Treatment).
A person ordered by the court to undergo treatment and who is without
a guardian may be transferred from one behavioral health provider
to another behavioral health provider, as long as the medical director
of the behavioral health provider initiating the transfer has established
that:
- There is
no reason to believe that the person will suffer more serious
physical harm or serious illness as a result of the transfer;
- The person
is being transitioned to a level and kind of treatment that is
more appropriate to the person’s treatment needs; and
- The medical
director of the receiving behavioral health provider has accepted
the person for transition.
The medical
director of the behavioral health provider requesting the transition
must have been the provider that the court committed the person
to for treatment or have obtained the court’s consent to transition
the person to another behavioral health provider as necessary.
The medical
director of the behavioral health provider requesting the transition
must provide notification to the receiving behavioral health provider
allowing sufficient time (but no less than 3 days) for the transition
to be coordinated between the behavioral health providers. Notification
of the request to transition must include:
- A summary
of the person’s needs;
- A statement
that, in the medical director’s judgment, the receiving
behavioral health provider can adequately meet the person’s
treatment needs;
- A modification
to the individual service plan, if applicable;
- Documentation
of the court’s consent, if applicable; and
- A written
compilation of the person’s treatment needs and suggestions
for future treatment by the medical director of the transitioning
behavioral health provider to the medical director of the receiving
behavioral health provider. The medical director of the receiving
behavioral health provider must accept this compilation before
the transition can occur.
Transportation
from the initiating behavioral health provider to the receiving
behavioral health provider is the responsibility of the initiating
behavioral health provider.
Due to tribal
sovereignty, A.R.S. § 36, Chapter 5 does not apply to members
of the Gila River Indian Community who may require court ordered
evaluation or treatment while residing on-reservation. Court ordered
evaluation and treatment procedures for Gila River Indian Community
members is prescribed in the Gila River Mental Health Ordinance
(GR-06-96). Providers are instructed to contact the Gila River RBHA
Clinical Manager for information regarding transitions of court
ordered persons.
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3.17
Transition of Persons
Last Revised: 09/09/2004
Effective Date: 12/15/2004 |
