3.9.1 Introduction
3.9.2 References
3.9.3 Scope
3.9.4 Did you know…?
3.9.5 Definitions
3.9.6 Procedures
3.9.6-A. Assessments
3.9.6-B: Service planning
3.9.6-C: Updates to the Assessment and Service Plan

3.9.1 Introduction
ADHS/DBHS supports a model for assessment, service planning and service delivery that is strength-based, person-centered, family friendly, culturally sensitive and clinically sound and supervised. The model is based on four equally important components:

• Input from the person and family/significant others regarding their individual needs, strengths and preferences;
• Input from other individuals who have integral relationships with the person;
• Development of a therapeutic alliance between the person and behavioral health provider that fosters an ongoing partnership built on mutual respect and equality; and
• Clinical expertise.

The model incorporates the concept of a “team”, established for each person receiving behavioral health services. . For children, this team is the Child and Family Team (CFT) and for adults, this team is the Adult Recovery Team.

At a minimum, the functions of the Child and Family Team and Adult Recovery Team include:

• Ongoing engagement of the person, family and others who are significant in meeting the behavioral health needs of the person, including their active participation in the decision-making process and involvement in treatment;
• An assessment process performed to (a) elicit information on the strengths, needs and goals of the individual person and his/her family, (b) identify the need for further or specialty evaluations, and (c) support the development and updating of a service plan which effectively meets the person’s/family's needs and results in improved health outcomes;
• Continuous evaluation of the effectiveness of treatment through the Child and Family Team and Adult Recovery Team process, the ongoing assessment of the person and input from the person and his/her team resulting in modification to the service plan, if necessary;
• Provision of all covered services as identified on the service plan, including assistance in assessing community resources as appropriate and, for children, services which are provided consistent with the Arizona Vision and Principles, and for adults, services which are provided consistent with the 9 Guiding Principles for Recovery Oriented Adult Behavioral Health Services and Systems;
• Ongoing collaboration, including the communication of appropriate clinical information, with other individuals and/or entities with whom delivery and coordination of services is important to achieving positive outcomes, (e.g., primary care providers, school, child welfare, juvenile or adult probation, other involved service providers);
• Oversight to ensure continuity of care by taking the necessary steps (e.g., clinical oversight, development of facility discharge plans, or after-care plans, transfer of relevant documents) to assist persons who are transitioning to a different treatment program, (e.g., inpatient to outpatient setting), changing behavioral health providers and/or transferring to another service delivery system (e.g., out-of-area, out-of-state or to an Arizona Long Term Care System (ALTCS) Contractor); and
• Development and implementation of transition plans prior to discontinuation or modification of behavioral health services.

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3.9.2 References
The following citations can serve as additional resources for this content area:

• 9 A.A.C. 20
• 9 A.A.C. 21
• AHCCCS/ADHS Contract
• ADHS/RBHA Contracts
• ADHS/TRBHA Intergovernmental Agreement
• Section 3.1, Eligibility Screening for AHCCCS Health Insurance, Medicare Part D Prescription Drug Coverage, and Limited Income Subsidy Program
• Section 3.2, Appointment Standards and Timeliness of Service
• Section 3.5, Third Party Liability and Coordination of Benefits
• Section 3.6, Member Handbooks
• Section 3.10, SMI Eligibility Determination
• Section 3.11, General and Informed Consent to Treatment
• Section 3.19, Special Populations
• Section 3.20, Credentialing and Recredentialing
• Section 3.21, Service Package for Non-Title XIX/XXI Persons Determined to have a Serious Mental Illness (SMI)
• Section 3.23, Cultural Competence
• Section 4.1, Disclosure of Behavioral Health Information
• Section 4.2, Behavioral Health Medical Record Standards
• Section 4.3, Coordination of Care with AHCCCS Health Plans, Primary Care Providers and Medicare Providers
• Section 5.4, Special Assistance for Persons Determined to have a Serious Mental Illness
• Section 7.5, Enrollment, Disenrollment and Other Data Submission
• ADHS/DBHS Covered Behavioral Health Services Guide
• ADHS/DBHS Demographic and Outcome Data Set User Guide (DUG)
• ADHS/DBHS Practice Protocol, Child and Family Team Practice
• ADHS/DBHS Practice Protocol, Working with the Birth to Five Population
• Arizona Visions and Principles
• 9 Guiding Principles for Recovery Oriented Adult Behavioral Health Services and Systems

3.9.3 Scope
To whom does this apply?
This applies to all providers who are conducting assessments or involved in the service planning process in the ADHS/DBHS behavioral health system.

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3.9.4 Did you know…?
There are seven basic principles on which this section is based. Behavioral health assessments and service plans:

1. Are developed with an unconditional commitment to persons enrolled in the behavioral health system and their families;
2. Begin with empathetic relationships that foster ongoing partnerships and built through respect throughout the service delivery system;
3. Build on a positive therapeutic alliance between the behavioral health provider and service recipient so that the service recipient feels comfortable with the provider and feels a sense of safety and trust in the treatment process;
4. Are developed collaboratively with families to engage and empower their unique strengths and resources;
5. Include other individuals important to the person;
6. Are individualized, strength-based, culturally appropriate and clinically sound; and
7. Are developed with the expectation that the person is capable of positive change, growth and leading a life of value.

While it may be feasible or even necessary to complete the assessment during one session, some individuals may benefit from and/or prefer that this process be conducted over the course of several clinical interviews and observations. For this reason, ADHS/DBHS allows up to 45 days for initial assessments to be completed to ensure a thorough and accurate evaluation (see Section 7.5, Enrollment, Disenrollment and Other Data Submission, for additional information on demographic data submission timeframes).

ADHS/DBHS established a medication benefit package for Non-Title XIX/XXI persons determined to have a Serious Mental Illness (SMI) (see Section 3.21, Service Package for Non-Title XIX/XXI Persons Determined to have a Serious Mental Illness (SMI)). Under the medication benefit package, assessments and coordination of care are primarily provided by nursing staff and behavioral health medical practitioners (BHMPs).

Behavioral health assessments and service plans must be completed by credentialed behavioral health professionals (BHPs) and behavioral health technicians (BHTs) who are trained on the minimum elements of the assessment and service plan contained in this policy (see Section 3.20, Credentialing and Recredentialing for credentialing requirements). Behavioral health providers who conduct assessments and develop service plans must also receive clinical supervision.

3.9.5 Definitions
Adult Recovery Team

Annual Update

Assessment

Behavioral Health Medical Practitioner

Behavioral Health Professional

Behavioral Health Technician

Child and Family Team

Clinical Teams

Credentialing

Family

Initial Assessment

Interim Service Plan

Individual Service Plan (ISP)

Special Assistance

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3.9.6 Procedures

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3.9.6-A: Assessments
All individuals being served in the public behavioral health system must have a behavioral health assessment upon an initial request for services. For individuals who continue to receive behavioral health services, updates to the assessment must occur at least annually. Behavioral health assessments must be utilized to collect necessary information that will inform providers of how to plan for effective care and treatment of the individual.

ADHS/DBHS does not mandate that a specific assessment tool or format be used but requires certain minimum elements. Providers must collect and submit all required demographic information in accordance with the criteria outlined in the ADHS/DBHS Demographic and Outcome Data Set User Guide (DUG) and Section 7.5, Enrollment, Disenrollment and Other Data Submission.

The initial and annual assessment must be completed by a behavioral health medical practitioner (BHMP), behavioral health professional (BHP) or behavioral health technician (BHT)) who is trained on the minimum elements of a behavioral health assessment and meets requirements in Section 3.20, Credentialing and Recredentialing. If an assessment is conducted and documented by a behavioral health technician, a behavioral health professional must review and sign the assessment information that was documented by the behavioral health technician.

Minimum elements of the behavioral health assessment
ADHS/DBHS has established the following minimum elements that must be included in a comprehensive behavioral health assessment and documented in the comprehensive clinical record, in accordance with Section 4.2, Behavioral Health Medical Record Standards:

• Vital signs and other parameters noted in ADHS/DBHS Provider Manual Section 3.15, Psychotropic Medication: Prescribing and Monitoring;
• Presenting issues/concerns;
• History of present illness, including review of major psychiatric symptoms (i.e., mood, depression, anxiety, psychosis, suicidal ideation, homicidal ideation, and other behavioral health symptoms) and frequency/duration of symptoms;
• Psychiatric history, including history of previous psychiatric hospitalization(s) and psychotropic medication trial(s);
• Medical history;
• Current medications, including over the counter (OTC) medications;
• Allergies and other adverse reactions;
• Developmental history for children/youth under the age of 18 and with other populations if clinically relevant;
• Family history;¹
• Educational history/status;*
• Employment history/status;
• Housing status;
• Social history;*
• Legal history, including custody/guardianship status, pending litigation, Court Ordered Evaluation/Court Ordered Treatment (COE/COT) history, criminal justice history, and any history of sex offender adjudication;
• Substance abuse history including type of substance, duration, frequency, route of administration, longest period of sobriety, and previous treatment history;
• Standardized substance use screen for children age 11 to 18 and referral for comprehensive assessment when screened positive;
• Substance use screen for adults age 18 and older using the American Society of Addiction Medicine (ASAM) Second Edition – Revised of Patient Placement Criteria (ASAM PPC-2R);
• Labs/ Diagnostics, if applicable;
• Mental Status Examination;
• Risk Assessment: the potential risk of harm to self or others based on self-reports, clinical symptoms, personality factors, past history, substance abuse, criminogenic factors, etc.;
• Brief summary/Bio-Psycho-Social formulation;
• Axial Diagnoses I-V; and
• Date, begin, and end time of the assessment and printed name, signature, and professional credential of the provider completing the behavioral health assessment. If a privileged BHT completes the assessment, the assessment must also include a printed name, signature, professional credential, date and time of the privileged BHP who reviewed the assessment information.
• REQUIRED FOR ALL TITLE XIX/XXI MEMBERS: Primary Care Provider (PCP) name and contact information.
• REQUIRED FOR ALL TITLE XIX/XXI MEMBERS: Involvement with other agencies (e.g., Child Protective Services, Probation, Division of Developmental Disabilities).
• ONLY REQUIRED FOR CHILDREN AGE 0 TO 5: Developmental screening for children age 0-5 with a referral for further evaluation by the child’s Primary Care Provider (PCP), the Arizona Early Intervention Program (AzEIP) for children age birth to three, or the public school system for children age three to five when developmental concerns are identified.
• ONLY REQUIRED FOR CHILDREN AGE 6 TO 18: Child and Adolescent Service Intensity Instrument (CASII) Score and Date.
• ONLY REQUIRED FOR CHILDREN AGE 6 TO 18 WITH CASII SCORE OF 4 OR HIGHER: Strength, Needs and Culture Discovery Document.
• ONLY IF INDICATED: Seriously Mentally Ill Determination (for persons who request SMI determination or have an SMI qualifying diagnosis and GAF score of 50 or lower) in accordance with Section 3.10, SMI Eligibility Determination.
• ONLY REQUIRED FOR PERSONS DETERMINED SMI: Special Assistance assessment by clinical team in accordance with Section 5.4, Special Assistance for Persons Determined to Have a Serious Mental Illness.
• For persons referred for or identified as needing ongoing psychotropic medications for a behavioral health condition, the assessor must establish an appointment with a licensed medical practitioner with prescribing privileges, in accordance with Section 3.2, Appointment Standards and Timeliness of Service. If the assessor is unsure regarding a person’s need for psychotropic medications, then the assessor must review the initial assessment and treatment recommendations with their clinical supervisor or a licensed medical practitioner with prescribing privileges.

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3.9.6-B: Service planning
All individuals being served in the public behavioral health system must have a written plan for services upon an initial request for services and periodic updates to the plan to meet the changing behavioral health needs for individuals who continue to receive behavioral health services. ADHS/DBHS does not mandate a specific service planning tool or format. Service plans must be utilized to document services and supports that will be provided to the individual, based on behavioral health service needs identified through the person’s behavioral health assessment.

If a person is in immediate or urgent need of behavioral health services (see Section 3.2, Appointment Standards and Timeliness of Service), an interim service plan may need to be developed to document services until a complete service plan is developed. A complete service plan, however, must be completed no later than 90 days after the initial appointment.

ADHS/DBHS has developed minimum elements for a service plan, as well as minimum elements for service plans for use with Non-Title XIX/XXI persons determined to have SMI who receive medication services (see Section 3.21, Service Package for Non-Title XIX/XXI Persons Determined to have a Serious Mental Illness (SMI)). Service plans must be completed by behavioral health medical practitioners, behavioral health professionals or behavioral health technicians who are trained on the behavioral health service plan and meet requirements in Section 3.20, Credentialing and Recredentialing. In the event that a behavioral health technician completes the service plan, a behavioral health professional must review and sign the service plan.

The behavioral health recipient must be included in the development of the service plan. In addition, family members, designated representatives, agency representatives and other involved parties, as applicable, may be invited to participate in the development of the service plan. Behavioral health providers must coordinate with the person’s health plan, PCP or others involved in the care or treatment of the individual, as applicable, regarding service planning recommendations (see Section 4.3, Coordination of Care with AHCCCS Health Plans, Primary Care Providers and Medicare Providers).

Minimum elements of the service plan for Title XIX/XXI Members
The service plan must be documented in the comprehensive clinical record in accordance with Section 4.2, Behavioral Health Medical Record Standards, be based on the current assessment, and contain the following elements:

• The person/family vision that reflects the needs and goals of the person/gamily;
• Identification of the person’s/family’s strengths;
• Measurable objectives and timeframes to address the identified needs of the person/family;
• Identification of the specific services to be provided and the frequency with which the services will be provided;
• The signature of the person/guardian and the date it as signed;
• Documentation of whether or not the person/guardian is in agreement with the plan;
• The signature of a clinical team member and the date it was signed;
• The signature of the person providing Special Assistance, for persons determined to have Serious Mental Illness who are receiving Special Assistance (see Section 5.4, Special Assistance for Persons Determined to have a Serious Mental Illness);
• The Service Plan Rights Acknowledgement (see Attachment 3.9.1, Service Plan Rights Acknowledgement Template), dated and signed by the person or guardian, the person who filled out the service plan, and a behavioral health professional if a behavioral health technician fills out the service plan.

The behavioral health recipient must be provided with a copy of his/her plan. Behavioral health recipients are encouraged to speak with their assigned Gila River RBHA Clinician should he/she have questions about their service plan and his/her rights regarding their service plan. Should questions or concerns still persist, behavioral health recipients can contact the Gila River Clinical Manager at 520-562-1200 or 602-528-7100.

Minimum elements of the service plan for Non-Title XIX/XXI persons determined to have SMI Service plans for Non-Title XIX/XXI persons determined to have SMI can be incorporated into the progress notes as long as the treatment goals reflect the need identified on the assessment are clearly documented and summarize the progress made. The behavioral health provider should clearly indicate when a clinical goal has been achieved or a new goal has been added.

What if the person and/or legal or designated representative disagree with the service plan?
Every effort should be taken to ensure that the service planning process is collaborative, solicits and considers input from each team member and results in consensus regarding the type, mix and intensity of services to be offered. In the event that a person and/or legal or designated representative disagree with any aspect of the service plan, including the inclusion or omission of services, the team should take reasonable attempts to resolve the differences and actively address the person’s and/or legal or designated representative’s concerns.

Despite a behavioral health provider’s best effort, it may not be possible to achieve consensus when developing the service plan.

In cases that the person and/or legal or designated representative disagree with some or all of the Title XIX/XXI covered services included in the service plan, the person and/or legal or designated representative must be given:

• A Notice of Action (PM Form 5.1.1) by the behavioral health representative on the team.

In cases that a person determined to have a Serious Mental Illness and/or legal or designated representative disagree with some or all of the Non-Title XIX/XXI covered services included in the service plan, the person and/or legal or designated representative must be given:

• PM Form 5.5.1, Notice of Decision and Right to Appeal (For Individuals With a Serious Mental Illness), by the behavioral health representative on the team.

In either case, the person and/or legal or designated representative may file an appeal within 60 days of the action.

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3.9.6-C: Updates to the Assessment and Service Plan
Behavioral health providers must complete an annual assessment update with input from the behavioral health recipient and family, if applicable that records a historical description of the significant events in the person’s life and how the person/family responded to the services/treatment provided during the past year. Following this updated assessment, the service plan should then be updated as necessary. While the assessment and service plan must be updated at least annually, the assessment and service plan may require more frequent updates to meet the needs and goals of the behavioral health recipient and his/her family.

¹ Additionally, confirm that sexual abuse/behavior information was documented as part of the person's Family, Educational, and Social History.

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3.9 Assessment and Service Planning
Last Revised: 07/29/11
Effective Date: 08/01/11