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 County Jails
4.4.7-H. Arizona Department of Economic Security/Rehabilitation
Services Administration (ADES/RSA)
4.4.7-I. Arizona Department of Health Services/Office of Assisted
Living Licensure
4.4.1
Introduction
Effective communication and coordination of services are fundamental
objectives for behavioral health providers when serving persons
involved with other government entities.
When behavioral health providers and public 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) (see
Section 3.2, Appointment
Standards and Timeliness of Service). 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. §8-8881
-
A.R.S.§ 15-825
-
A.R.S. §15-1181(12)
-
9 A.A.C.10-701
-
9 A.A.C.21
-
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, 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 the following:
- Arizona Health Care Cost
Containment System (AHCCCS);
-
Arizona Department of Economic Security/Division of Children,
Youth and Families (ADES/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);
-
AHCCCS/Arizona Long
Term Care Services (ALTCS); and
- ADES/Arizona
Early Intervention Program (AZEIP).
- ADHS/DBHS
has Intergovernmental Agreements (IGAs),
Interagency Service Agreements (ISAs) and
Memorandums of Understanding (MOUs)
with several State, county, Tribal and local agencies to collaborate
while serving persons involved with multiple systems.
- ADHS/DBHS
has developed a
Practice Protocol, Child
and Family Team Practice.
The protocol includes suggested guidelines for developing and
maintaining a collaborative relationship with other government
entities that deliver services to children.
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4.4.5 Definitions
Child and
Family Team (CFT)
Adult Clinical Team
Individualized Education Program (IEP)
State Placing Agencies
4.4.6
Objectives
ADHS/DBHS endorses a collaborative process of assessment, service planning, service delivery, and support among multiple agencies to
ensure that the care a person receives from a behavioral health service
provider is effectively coordinated with other government entities.
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 Tribal and Regional Behavioral Health Authorities (T/RBHAs), 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 Arizona's 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 Specialist. Behavioral health providers are expected to:
- Coordinate
the development of the behavioral health service plan with the
child welfare case plan to avoid redundancies and/or inconsistencies;
- Ensure an
urgent response to DCYF initiated referrals for children who
have been removed from their homes
(see Section 3.2,
Appointment Standards and Timeliness of Service);
- Provide
the CPS Specialist 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;
- Work collaboratively on child placement decisions if placement and funding
are being sought for behavioral health treatment;
- Invite
the CPS Specialist, CPS providers and resource parents to participate
in the behavioral health assessment and service planning process
as members of the Child and Family Team (CFT) (see Section
3.9, Assessment and Service Planning);
- Strive 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 CFT toward the behavioral health needs of the child, and
the team should seek the active participation of other involved agencies in the
planning process.
- Attend 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.
- Coordinate,
communicate and expedite necessary behavioral health services to
stabilize in-home and out-of-home placements provided by DCYF;
- Provide 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
- Ensure
responsive coordination activities and service delivery that
supports DCYF planning and facilitates adherence to DCYF established
timeframes (see
Practice Protocol, 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 caregivers referred by ADES/DCYF/DPS
and the ADES/FAA Jobs Program. ADHS/DBHS participates in statewide
implementation of the program with ADES (see
A.R.S. 8-8881). 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 persons and families referred through AFF and provide services,
if eligible (see
Section 3.19,Special Populations and Section 3.21, Service Package for Non-Title XIX/XXI
Persons Determined to have a Serious Mental Illness (SMI)).
- Ensure that services made available to persons
who 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 service delivery 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.
The goal of the AFF Program is to promote permanency for children, stability for families, protect the health and safety of abused and/or neglected children and promote economic security for families. Substance abuse treatment to families involved with DES/DCYF/CPS must be family centered, provide for sufficient support services and provided in a timely manner (see
Section 3.2. Appointment Standards and Timeliness of Service, 3.2.7-G, Special Populations).
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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, actively consider information and recommendations contained in the IEP in the ongoing assessment and service planning process (see
Section 3.9, Assessment and Service Planning);
- For children receiving special education services, ensuring that the behavioral health provider or designee participates with the school in developing the child’s (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;
- Having clear understanding of the IEP requirements as described in the
Individuals with Disabilities Education Act (IDEA) of 2004;
- Ensuring that students with disabilities who qualify for accommodations under
Section 504 of the Rehabilitation Act of 1973 are provided adjustments in the academic requirements and expectations necessary to accommodate their needs and enable them to participate in the general education program;
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 eligibility for services* |
T/RBHAs
and contracted providers based on eligibility for services* |
*See
Section 3.19, Special Populations,
and Section 3.21, Service Package for Non-Title XIX/XXI Persons
Determined to have a Serious Mental Illness.
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, Assessment and Service Planning);
-
Incorporating information and recommendations in the Individual
or Family Support Plan (ISP) developed by DDD staff, when
appropriate, while developing
the person’s ISP;
- Ensuring
that the goals of the ISP of a person diagnosed
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; and
- For persons
diagnosed with Pervasive Developmental Disorders and Developmental
Disabilities, sharing all relevant information, from the initial
assessment and ISP with DDD to ensure coordination
of services.
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 behavioral
health provider will coordinate team functions so as to avoid duplicative
processes between systems;
-
Coordinating enrollment in the
T/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)
- 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 ISP 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 ISP; and
- Ensuring
that 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 Department
of Rehabilitation and Supervision (JDRS); and
Department of Rehabilitation and Supervision (DRS)
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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, SMI Eligibility Determination) and is detained in a
Maricopa County jail, the behavioral health provider must 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 in Maricopa County and all other Arizona
counties, behavioral health providers must help ensure that appropriate
coordination also occurs for behavioral health recipients with jail personnel
at other county jails.
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 Services/Office of Assisted Living Licensure
When a person receiving behavioral health services is also residing
in an assisted living facility, 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.
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4.4
Coordination of
Care with Other Government Entities
Last Revised:05/13/2011
Effective Date: 09/01/2011
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