Section
4.4 Coordination of Care with Other Government Entities
4.4.1
Introduction
4.4.2 References
4.4.3 Scope
4.4.4 Did you know …?
4.4.5 Definitions
4.4.6 Objectives
4.4.7 Procedures
4.4.7-A. General requirements
4.4.7-B. Arizona Department of Economic Security/Division
of Children, Youth and Families (ADES/DCYF)
4.4.7-C. Arizona Department of Education (ADE),
Schools or Other Local Educational Authorities
4.4.7-D. Arizona Department of Economic Security/Division
of Developmental Disabilities (ADES/DDD)
4.4.7-E. Arizona Department of Economic
Security/Arizona Early Intervention Program (ADES/AzEIP)
4.4.7-F. Courts and Corrections
4.4.7-G. Arizona Department of Corrections (ADOC)/Corrections Officer/Offender Liaison (COOL)
Program
4.4.7-H. Arizona County Jails
4.4.7-I. Arizona Department of Economic Security/Rehabilitation
Services Administration (ADES/RSA)
4.4.7-J. Arizona Department of Health/Office of Assisted
Living Licensure
4.4.7-K. Unlicensed Board and Care Homes
4.4.1
Introduction
Effective communication and the coordination of services are fundamental
objectives for behavioral health providers when serving persons
involved with other government entities (e.g., state agencies).
When a behavioral health provider and other government entities,
including their service providers, coordinate care efficiently,
the following positive outcomes can occur:
- Duplicative
and redundant activities, such as assessments, service plans and
agency meetings are minimized;
- Continuity and consistency of care
are achieved;
- Clear lines
of responsibility and accountability across service providers in
meeting the needs of the person and family are established; and
- Limited resources
are effectively utilized.
The Arizona Department of Health Services/Division
of Behavioral Health Services (ADHS/DBHS) recognizes
the importance of a responsive behavioral health system, especially
when the needs of vulnerable persons have been identified by other
government entities. For example, ADHS/DBHS strongly supports the
timely response and coordination of services for children who have
been, or imminently will be, removed from their homes by the Arizona Department of
Economic Security/Child Protective Services (ADES/CPS). ADHS/DBHS expects all behavioral health providers
to collaborate and provide any necessary assistance when CPS initiates
requests for behavioral health services or supports.
The intent of
this section is to convey the ADHS/DBHS expectation that behavioral
health providers cooperate and actively work with other agencies
involved with the same person.
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4.4.2
References
The following citations can serve as additional resources for this
content area:
-
A.R.S. §15-1181(12)
-
A.R.S.§ 15-825
-
A.A.C.R9-10-701
-
AHCCCS/ADHS Contract
-
ADHS/RBHA Contracts
-
ADHS/TRBHA IGAs
- Section 3.2, Appointment Standards and Timeliness of Service
-
Section 3.3, Intake and Referral Process
-
Section 3.8, Outreach, Engagement, Re-Engagement and Closure
-
Section 3.9, Assessment and Service Planning
-
Section 3.10, Serious Mental Illness (SMI) Eligibility Determination
-
Section 4.1, Disclosure of Behavioral Health Information
-
Section 4.2, Behavioral Health Medical Records Standards
-
Section 4.3, Coordination of Care with AHCCCS Health Plans, Primary Care Providers and Medicare Providers
-
ADHS/DBHS Covered Behavioral Health Services Guide
-
Practice Protocol 8, The Adult Clinical Team
-
Practice Protocol, Child and Family Team
Practice
-
Practice Protocol ,The Unique Behavioral Health Service Needs of Children, Youth, and Families Involved with CPS
-
Governor’s Executive Order 2008-01
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4.4.3
Scope
To whom does this apply?
All persons
receiving behavioral health services involved with any other government
entities.
4.4.4
Did you know?
- Persons receiving
behavioral health services may be involved with other ADHS/DBHS
Divisions or government entities, including:
- Arizona Health Care Cost
Containment System (AHCCCS);
- Arizona
Department of Economic Security (ADES) Division of Children,
Youth and Families (DCYF);
- Arizona
Department of Juvenile Corrections (ADJC);
- Administrative
Office of the Arizona Supreme Court (AOC);
- Arizona
Department of Education (ADE);
- ADES/Rehabilitation
Services Administration (RSA);
- ADHS/Children’s
Rehabilitative Services Administration (CRSA);
- Tribal
social services and Tribal courts;
- Arizona
Department of Corrections (ADOC);
- ADES
Division of Developmental Disabilities (DDD) [Arizona Long
Term Care Services (ALTCS)]; and
- Arizona
Early Intervention Program (AZEIP).
- ADHS/DBHS
has entered into Intergovernmental Agreements (IGAs), Interagency
Service Agreements (ISAs) and Memorandums of Understanding (MOUs)
with several State, county, Tribal and local agencies to ensure
collaboration in serving persons involved with multiple systems.
- ADHS/DBHS
has developed a Child
and Family Team Practice Improvement Protocol.
The protocol includes suggested guidelines for developing and
maintaining a collaborative relationship with other government
entities that deliver services to children.
- A collaborative
process of assessment, service planning, service delivery and
support among multiple agencies represents the practice endorsed
by ADHS/DBHS.
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4.4.5 Definitions
Child and
Family Team (CFT)
Adult Clinical Team
Assisted Living Facility
State Placing Agencies
4.4.6
Objectivesss
To make sure that the care a person receives from a behavioral health service
provider is effectively coordinated with other government entities concurrently
providing services to the person in accordance with Provider Manual
Section 3.2,
Appointment Standards and Timeliness of Service and Provider Manual
Section 3.9,
Assessment and Service Planning and Provider Manual
Section 4.3, Coordination of Care
with AHCCCS Health Plans, Primary Care Providers and Medicare Providers.
4.4.7
Procedures
Behavioral health providers are responsible for actively
coordinating the services a person receives with the services provided
by other government entities. Behavioral health service providers,
in cooperation with the contracting T/RBHA, must coordinate efforts
with other government entities and their service providers.
4.4.7-A.
General requirements
The following information represents the ADHS/DBHS requirements
for behavioral health providers when collaborating and coordinating
care with other government entities that may be involved with persons
receiving services in the public behavioral health system.
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4.4.7-B:
Arizona Department of Economic Security/Division of Children, Youth
and Families (ADES/DCYF)
When a child receiving behavioral health services is also
receiving services from ADES/DCYF, the behavioral health provider
can work towards effective coordination of services by working in
collaboration with the CPS case worker and:
- Coordinating
the development of the behavioral health service plan with the
child welfare case plan to avoid redundancies and/or inconsistencies;
- Ensuring
an urgent response to DES/DCYF initiated referrals for children
who have been, or imminently will be, removed from their homes
(see Section 3.2,
Appointment Standards and Timeliness of Service);
- Providing
the CPS case worker and the juvenile court with preliminary findings and
recommendations on behavioral health risk factors, symptoms and service needs for
consideration in the development of the child’s CPS case plan for the initial
preliminary protective hearing;
- Working collaboratively on child placement decisions if placement and funding
are being sought for behavioral health treatment;
- Inviting
the CPS case worker, CPS providers and foster parents to participate
in the behavioral health assessment and service planning process
as members of the child and family team (see Section
3.9, Intake, Assessment and Service Planning);
- Striving to be consistent with the service goals established by other agencies
serving the child or family. Behavioral health service plans must be directed by
the Child and Family Team (CFT) toward the behavioral heath needs of the child, and
the team should seek the active participation of other involved agencies in the
planning process.
- Attending team meetings such
as Team Decision Making (TDM) and Family Group Decisions (as appropriate) for the
purpose of providing input about the child and family’s behavioral health needs.
Where it is possible, TDM and CFT meetings should be combined.
- Coordinating,
communicating and expediting behavioral health services to assist
DES/DCYF in enhancing safety to keep families together, reducing
the amount of time children spend in the custody of the state,
improving the stability of out-of-home placements and assisting
in finding permanent placement for children;
- Providing behavioral health
services during the reunification process and/or other permanency plan options
facilitated by DCYF. Parent-child visitation arrangements and supervision are the
responsibility of CPS. Therapeutic visitation is not a covered behavioral health
service.; and
- Ensuring
responsive coordination activities and service delivery that supports
DES/DCYF planning and facilitates adherence to DES/DCYF established
timeframes (see
Practice Improvement Protocol 15, The Unique Behavioral Health
Service Needs of Children, Youth, and Families Involved with CPS).
ADES/ADHS Arizona Families F.I.R.S.T.
(Families in Recovery Succeeding Together)
Behavioral health providers must ensure coordination for parents/families
referred through the Arizona Families F.I.R.S.T (AFF) program (see
Attachment 4.4.2, Arizona
Families F.I.R.S.T. (AFF) Program Model and Referral Process).
The AFF program provides expedited access to substance abuse
treatment for parent and families referred by Child Protective Services
and the ADES Jobs Program. ADHS/DBHS participates in statewide implementation
of the program through an IGA with ADES. T/RBHAs and providers must:
- Accept referrals
for Title XIX and Title XXI eligible and enrolled persons and
families referred through AFF;
- Accept referrals for Non-title XIX and Non-title XXI eligible and enrolled persons and families referred through AFF and provide services as funding permits (see Section 3.2.1, Service Prioritization for Non-title XIX/XXI Funding).
- Ensure that services made available to persons that are Non-title XIX and Non-title XXI eligible are provided by maximizing available federal funds before expending state funding as required in the Governor’s Executive Order 2008-01;
- Collaborate with ADES/DCYF/CPS, ADES/FAA Jobs Program and Substance Abuse Treatment providers to minimize duplication of assessments and achieve positive outcomes for families; and
- Develop procedures for collaboration in the referral process to ensure effective communication, including the sharing information on persons who are involved in the AFF program and receiving services through the T/RBHA behavioral health system. Appropriate authorizations to release information must be obtained prior to releasing information.
Due to tribal
sovereignty, ADES/DCYF has no jurisdiction on Arizona Indian reservations.
Tribal Social Services (TSS) is the child welfare agency responsible
for serving residents and members of the Gila River Indian Community.
The Gila River RBHA expedites referrals from TSS for children who
have been removed from their home or are at imminent risk for removal.
The Gila River RBHA and subcontracted behavioral health providers
coordinate closely with TSS caseworkers through clinical staffings
and joint treatment planning to enhance child safety and maximize
treatment effectiveness.
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4.4.7-C:
Arizona Department of Education (ADE), Schools or Other Local Educational
Authorities
ADHS/DBHS has delegated the functions and responsibilities as a State Placing Agency
to the T/RBHAs. As such it is the expectation of ADHS/DBHS that RBHAs work in
collaboration with the ADE for the placement of children with behavioral health
service providers.
Behavioral health providers serving children can gain valuable
insight into an important and substantial element of a child’s
life by soliciting input from school staff and teachers. Behavioral
health providers can collaborate with schools and help a child achieve
success in school by:
- Working
in collaboration with the school and sharing information to the
extent permitted by law and authorized by the child’s parent
or legal guardian (see Section
4.1, Disclosure of Behavioral Health Information);
- For children
receiving special education services, ensuring that the clinical
liaison or designee participates with the school in developing
the child’s Individual Education Plan (IEP) and share the behavior
treatment plan interventions, if applicable;;
- Inviting
teachers and other important school staff to participate in the
child and family team if agreed to by the child and legal guardian;
- Actively
considering information and recommendations contained in the (IEP)
in the ongoing assessment and service planning process (see Section
3.9, Intake, Assessment and Service Planning); and
- Ensuring
that transitional planning occurs prior to and after discharge
of an enrolled child from any out-of-home placement.
The Gila River
RBHA and subcontracted providers collaborate with on-reservation
public schools as well as schools funded through the Bureau of Indian
Affairs (BIA).
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4.4.7-D.
Arizona Department of Economic Security/Division of Developmental
Disabilities (ADES/DDD)
Persons qualifying for services through DDD can fall into several
different categories based on their eligibility status and the extent
of their disability. There are three general groupings:
| Type
of DDD Eligibility |
What
behavioral health services are available? |
Who
is responsible for providing the behavioral health services? |
| Title XIX
and eligible for ALTCS |
All Title
XIX covered services |
T/RBHAs
and contracted providers |
| Title XIX
and not eligible for ALTCS |
All Title
XIX covered services |
T/RBHAs
and contracted providers |
| Non-Title
XIX |
Services
provided based on available funding |
T/RBHAs
and contracted providers based on the availability of funds |
Behavioral health
providers can strive towards effective coordination of services
with persons receiving services through DDD by:
- Working
in collaboration with DDD staff and service providers involved
with the person;
- Providing
assistance to DDD providers in managing difficult behaviors:
- Invite DDD staff to participate
in the development of the behavioral health service plan and all
subsequent planning meetings as members of the person’s
clinical team (see Section
3.9, Intake, Assessment and Service Planning);
-
Incorporating information and recommendations in the Individual
or Family Support Plan developed by DDD staff when developing
the person’s behavioral health treatment plan;
- Ensuring
that the goals of the behavioral health treatment plan of a person
with developmental disabilities who is receiving psychotropic
medications includes reducing behavioral health symptoms and achieving
optimal functioning, not merely the management and control of
behavior;
- Actively
participating in DDD team meetings when invited; and
- For persons
diagnosed with Pervasive Developmental Disorders and Developmental
Disabilities, sharing all relevant information, from the initial
assessment and treatment plan with DDD and to ensure coordination
of services.
Arizona Early
Intervention Program (AzEIP) behavioral health service providers
can strive toward effective coordination of care for children identified
as having, or likely having developmental delays by:
- Ensuring
that children are referred to AZEIP in a timely manner when information
obtained in their behavioral health assessment reflects developmental
concerns;
- Ensuring
that children found to require behavioral health services as part
of the AZEIP evaluation process receive appropriate and timely
service delivery (see
Section
3.2, Appointment Standards and Timeliness of Service);
and
- Ensuring
that, if an AZEIP team has been formed for the child, the Clinical
Liaison will coordinate team functions so as to avoid duplicative
processes between systems.
Although the
RBHAs are capitated to serve all Title XIX persons who are DDD ALTCS
eligible, the Gila River RBHA serves a small number of DDD ALTCS
members as a courtesy to the capitated behavioral health system.
The Gila River RBHA and subcontracted providers refer children identified
with possible developmental delays to the Arizona Early Intervention
Program and coordinate with the AzEIP team as appropriate.
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4.4.7-E. Arizona Department of Economic Security/Arizona Early
Intervention Program (ADES/AzEIP)
Behavioral
health service providers can strive toward effective coordination of
care for children identified as having, or likely having,
disabilities or developmental delays by:
-
Ensuring
that children birth to three years of age are referred to AzEIP in a
timely manner when information obtained in their behavioral health
assessment reflects developmental concerns;
-
Ensuring
that children found to require behavioral health services as part of
the AzEIP evaluation process receive appropriate and timely service
delivery (see Section 3.2, Appointment Standards and Timeliness
of Service); and
-
Ensuring
that, if an AzEIP team has been formed for the child, the Clinical
Liaison will coordinate team functions so as to avoid duplicative
processes between systems;
-
Coordinating enrollment in the RBHA
children’s system of care when a child transfers to the children’s DDD system;
4.4.7-F.
Courts and Corrections
- Arizona
Department of Corrections (ADC)
- Arizona Department
of Juvenile Corrections (ADJC); and
- Administrative
Offices of the Court (AOC)
When a person
receiving behavioral health services is also involved with a court
or correctional agency, behavioral health providers can work towards
effective coordination of services by:
- Working in
collaboration with the appropriate staff involved with the person
- Inviting
probation or parole personnel to participate in the development
of the behavioral health service plan and all subsequent planning
meetings as members of the person’s clinical team;
- Actively
considering information and recommendations contained in probation
or parole case plans when developing the behavioral health service
plan; and
- Ensuring
that upon referral or request, the behavioral health provider
evaluates and participates in transition planning prior to the
release of eligible persons and arranges and coordinates care
upon the person’s release (see Section
3.3, Intake and Referral Process).
Behavioral health
providers serving Gila River RBHA enrolled members collaborate with
the Gila River courts and with the following tribal correctional
entities:
Juvenile Detention
and Rehabilitation Center (JDRC); and
Department of Corrections and Rehabilitation (DOCR)
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4.4.7-G.
Arizona County Jails
In Maricopa County, when a person receiving behavioral health services
has been determined to have, or is perceived to have, a serious
mental illness (see Section 3.10,
Serious Mental Illness (SMI) Eligibility Determination) and is detained in a
Maricopa County jail, the behavioral health provider can assist
the person by:
- Working
in collaboration with the appropriate staff involved with the
person;
- Ensuring
that screening and assessment services are provided to jailed
persons upon request;
- Ensuring
that the person has a viable discharge plan, that there is continuity
of care if the person is discharged or incarcerated in another
correctional institution and that pertinent information is shared
with all staff involved with the person’s care or incarceration
in accordance with Section 4.1,
Disclosure of Behavioral Health Information; and
- Determining
whether the person is eligible for the Jail Diversion Program.
For all other
persons receiving behavioral health services and all other Arizona
counties, behavioral health providers must help ensure that appropriate
coordination with jail personnel occurs.
Gila River RBHA
behavioral health providers collaborate with jail personnel at on-reservation
correctional facilities and at county jails in cases where members
are incarcerated on charges outside the jurisdiction of the reservation.
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4.4.7-H.
Arizona Department of Economic Security/Rehabilitation Services
Administration (ADES/RSA)
The purpose of RSA is to work with individuals with disabilities
to achieve increased independence or gainful employment through
the provision of comprehensive rehabilitative and employment support
services in a partnership with all stakeholders.
Supportive employment
services available through the ADHS/DBHS system are distinct from
vocational services available through RSA. Please refer to the ADHS/DBHS
Covered Behavioral Health Services Guide for more details.
When a person
determined to have a Serious Mental Illness is receiving behavioral
health services and is concurrently receiving services from RSA,
the behavioral health provider can ensure effective coordination
of care by:
- Working in
collaboration with the vocational rehabilitation (VR) counselors
or employment specialists in the development and monitoring of
the person’s employment goals;
- Ensuring
that all related vocational activities are documented in the comprehensive
clinical record (see
Section 4.2,
Behavioral Health Medical Records Standards);
- Inviting
RSA staff to be involved in planning for day programming to ensure
that there is coordination and consistency with the delivery of
vocational services;
- Participating
and cooperating with RSA in the development and implementation
of a Regional Vocational Service Plan; and
- Allocating
space and other resources for VR counselors or employment specialists
working with enrolled persons who have been determined to have
a serious mental illness.
Gila River RBHA
behavioral health providers collaborate with ADES/RSA local offices
throughout Maricopa and Pinal counties to ensure that vocational
services are coordinated with the provision of covered behavioral
health services.
4.4.7-I.
Arizona Department of Health/Office of Assisted Living Licensure
When a person receiving behavioral health services is also residing
in an assisted living facility or a supervisory care home, behavioral
health providers must coordinate with the Office of Assisted Living
to ensure that the facility is licensed and that there are no existing
violations or legal orders. Behavioral health providers must also
determine and ensure that the person living in an assisted living
facility is at the appropriate level of care. The behavioral health
provider can coordinate with the Office of Assisted Living to determine
the level of care that a particular assisted living facility is
licensed to provide.
4.4.7-J.
Unlicensed Board and Care Homes
When a person who is receiving behavioral health services is also
residing in a unlicensed board and care home, behavioral health
providers must ensure that the person’s basic needs are met
in an environment that is safe, secure and consistent with the person’s
behavioral needs. The behavioral health provider must ensure that
any situations observed that pose a threat to the health or safety
of the person is resolved. Any observations of unsafe conditions
should be reported to the local housing authority.y.
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4.4
Coordination of
Care with Other Government Entities
Last Revised:07/01/2009
Effective Date: 07/01/2009
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