Department of Youth Services Guide to New and Current MassHealth Behavioral Health Services & Department of Youth Services Protocols Table of Contents Section 1 MassHealth: New and Current Services Pg 3 Section 2 Department of Youth Services Protocols Pg 13 Section 1 MassHealth: New and Current Services I. The Children’s Behavioral Health Initiative (CBHI) The Children’s Behavioral Health Initiative is an interagency initiative of the Commonwealth’s Executive Office of Health and Human Services whose mission is to strengthen, expand and integrate Massachusetts state services into a comprehensive, community-based system of care, to ensure that families and their children with significant behavioral, emotional and mental health needs obtain the services necessary for success in home, school and community. The Children’s Behavioral Health Initiative is defined by a shared commitment to providing services to families that reflect the following values: * Family Driven, Child-Centered and Youth Guided Services are driven by the needs and preferences of the child and family, developed in partnership with families and accountable to families. * Strengths-based Services are built on the strengths of the family and their community * Culturally Responsive Services are responsive to the family’s values, beliefs, norms, and to the socio-economic and cultural context. * Collaborative and Integrated Services are integrated across child-serving agencies and programs. * Continuously Improving Service improvements reflect a culture of continuous learning, informed by data, family feedback, evidence and best practice. The Initiative places the family and child at the center of our service delivery system, and will build an integrated system of behavioral health services that meets the individual needs of the child and family. The goal is to make it easier for families to find and access appropriate services and to ensure that families feel welcome, respected and receive services that meet their needs, as defined by the family. For more information visit: www.mass.gov/masshealth/childbehavioralhealth II. MassHealth: New and Current Services MassHealth pays for many important health care services for a wide range of people who meet the eligibility rules. In 2009, MassHealth significantly expanded behavioral health services available to its MassHealth Standard and CommonHealth members under the age of 21 by paying for six new home and community-based services. The goal of these services is to help children and youth with significant behavioral, emotional and mental health needs achieve success in home, school and community. These services have been designed, and are being implemented according to Children’s Behavioral Health Initiative Values: * Family Driven, Child-Centered and Youth Guided * Strengths-based * Culturally Responsive * Collaborative and Integrated * Continuously Improving These new services complement the behavioral health services currently available to MassHealth Standard and CommonHealth members under the age of 21. Below, you will find brief descriptions of the new services, and of the current community-based MassHealth Behavioral Health Services. NOTE: These new services are NOT for the treatment of the behavioral health needs of a youth’s parents or caregivers. Behavioral Health services for parents or caregivers should be sought through their health care insurer, or MassHealth, if they are eligible. New MassHealth Community-Based Behavioral Health Services What follows are brief descriptions of the new services, with some suggestions of who might benefit from each of the new services. This information is intended to provide staff with guidance on how to help families and youth to access appropriate MassHealth behavioral health services. It is important to note that MassHealth members may also self-refer to any behavioral health service they think might be helpful. Families and youth are always welcome to inquire with a provider about a particular service. This guidance is intended to be informative and to illustrate the potential usefulness of each service. It does NOT replace the Medical Necessity Criteria, attached in Appendix B. Providers of each of the services will use the Medical Necessity Criteria (MNC) to evaluate whether the child or youth has a medical need for the service. Medical Necessity decisions made by providers may be reviewed by the child’s or youth’s MassHealth Managed Care Plan. A. Standardized Behavioral Health Screening in Primary Care As part of well-child visits, the primary care doctor or nurse checks the child’s or youth’s health, development, need for immunizations, dental health and behavioral health. MassHealth now requires primary care doctors or nurses to offer to use a behavioral health screening tool to check the child’s or youth’s behavioral health. There are eight approved screening tools. They typically consist of a short list of questions, or a checklist, that the parent, caregiver or youth fills out and then talks about with the primary care doctor or nurse. The screening tool helps to spot concerns early so problems can be found and helped earlier. If there are concerns about a child’s or youth’s behavioral health, the primary care doctor or nurse will work with the parent/caregiver or youth to decide if a referral to a behavioral health provider for further assessment and treatment is needed, and can help the parent/caregiver/youth get needed services. B. Standardized Behavioral Health Assessment, using the Child Adolescent Needs and Strengths tool (CANS) Beginning November 30, 2008, MassHealth began requiring a uniform behavioral health assessment process for MassHealth members under the age of 21 receiving behavioral health services. The uniform behavioral health assessment process includes a comprehensive needs assessment using the Child and Adolescent Needs and Strengths (CANS) tool. The CANS is a tool that organizes clinical information collected during a behavioral health assessment in a consistent manner, to improve communication among those involved in planning care for a child or youth. The CANS is also used as a decision-support tool to guide care planning, and to track changing strengths and needs over time. The CANS is used in child and youth serving systems in more than 30 states. There are two forms of the Massachusetts CANS: CANS Birth through Four and CANS Five through Twenty. Both versions include questions that enable the assessor to determine whether a child meets the criteria for Serious Emotional Disturbance (SED), in addition to the CANS assessment questions. (Meeting the definition of SED is a component of the Medical Necessity Criteria for the new service Intensive Care Coordination.) C. Intensive Care Coordination (starting June 30, 2009) ICC is a care coordination service for children and youth with serious emotional disturbance (For definitions of Serious Emotional Disturbance, see ICC Medical Necessity Criteria, Appendix B). ICC will use a model called Wraparound Care Planning. In Wraparound Care Planning, families and youth work together with professionals, talk about their strengths and needs, and actively guide their own care. In ICC, a team leader, called a Care Coordinator, helps families bring together a team of people to create a child’s treatment plan. This Care Planning Team often includes therapists, teachers, social workers and representatives of all child-serving agencies involved with the youth. It also includes “natural supports”, such as family members, friends and people from the family’s neighborhood or community that the family invites to be part of the team. Together, the team comes up with ways to support the family’s goals for the child (or youth’s goals, in the case of an older child), creating an Individual Care Plan. This plan, which also focuses on the family’s strengths and respects their cultural preferences, lists all the behavioral health, social, therapeutic or other services needed by the child and family including informal and community resources. It will guide the youth’s care and involve all providers and state agencies to integrate services. The Care Planning Team will usually meet monthly and sometimes more often for children and youth with more complex needs. At these meetings the family, youth and other team members can talk about progress, work to solve problems, and make any needed changes to the Individual Care Plan. Additionally the ICC care planning team seeks to: * Help the family obtain and coordinate services the youth needs and/or receives from providers, state agencies, special education, or a combination thereof * Assist with access to medically necessary services and ensure these services are provided in a coordinated manner * Facilitate a collaborative relationship among a youth with SED, his/her family, natural supports, and involved child-serving systems to support the parent/caregiver in meeting their youth’s needs Who is likely to need ICC? Children and families who need or receive services from multiple providers or who need or receive services from multiple state agencies, including special education. ICC can help prioritize goals and monitor progress, ensuring that interventions being used are effective and coordinated. ICC can also address needs other than behavioral health needs, such as connecting families with a variety of sustainable supports. Examples of sustainable supports include recreational activities for the child or youth, connection to mentors and opportunities for mutual support and social interaction with other families. Who may benefit from referral to a different service? > A child or youth in acute emotional, behavioral or mental health crisis. Consider referring instead to Mobile Crisis Intervention for immediate stabilization and support. > Family of a child or youth with a single service need who does not need a Care Planning Team to coordinate services: Consider referring instead to the service(s) that may be needed. > A family in too much immediate distress to participate in the team-based sequence of steps of the Wraparound process. Consider referring first to another behavioral health service such as Family Stabilization Teams (until November 1, 2009) or In-home Therapy (available November 1 2009, during which the need for other services including ICC will be assessed). How do I make a referral? See the list of Community Service Agencies in Appendix A. Geographically-Based CSAs: MassHealth’s Managed Care Contractors have selected 29 Community Service Agencies (CSAs), one for each of 29 service areas. The service areas correspond to the Areas of the Department of Children and Families. Culturally and Linguistically Specialized CSAs: MassHealth’s Managed Care Contractors have also selected 3 culturally and linguistically specialized CSAs. These CSAs were chosen for their demonstrated ability to reach deeply in to specific cultural or linguistic communities and tailor their services to engage and serve their specified populations. Like all CSAs, Specialized CSAs are expected to serve any family seeking appropriate service without regard to race, ethnicity or language. o Children’s Services of Roxbury specializes in serving the African-American population in Greater Boston. o The Gandara Center specializes in serving the Latino population in the Springfield/Holyoke area. o The Learning Center for the Deaf, Walden School specializes in serving the Deaf and Hard of Hearing population, particularly in the eastern/central part of the state. Families with children or youth enrolled in MassHealth are not required to choose a CSA in their area or a culturally or linguistically specialized CSA, but may choose to work with any CSA. For more specific information about how to access these services on behalf of a youth enrolled in a MassHealth managed care plan contact the plan directly. Contact numbers for the plans are listed at the end of this section. D. In-Home Therapy (starting November 1, 2009) In-Home Therapy Services provides intensive family therapy for a child and family for the purpose of treating the youth’s behavioral health needs, including improving the family’s ability to provide effective support for the youth to promote his/her healthy functioning within the family. In-Home Therapy Services are provided in the home or other location which is appropriate and convenient to the family. It is provided by a skilled behavioral health provider who may work in a team with a paraprofessional. In-Home Therapy providers work to understand how the family functions together and how these relationships can be strengthened to benefit the child. Together with the child and family, they create and implement a treatment plan. Goals in a treatment plan might include helping the family identify and use community resources, learn to more effectively set limits and establish helpful routines for their child, problem-solve difficult situations or change family behavior patterns that get in the way of their child’s success. Note: Parents may also have individual behavioral health needs that may require separate behavioral health treatment. Who is likely to need In-Home Therapy? > Families in need of more urgent or intensive help with a youth’s emotional and behavioral challenges than could be addressed through outpatient therapy. > Families that have identified their primary need as learning new ways to relate to one another, or new ways to set limits or regulate child behavior, or who have tried outpatient therapy but not found it effective. IHT offers more flexibility than outpatient therapy, not only in intensity but in treatment setting. Therapeutic intervention in a natural environment can offer opportunities for understanding behavior and for rehearsing new strategies which are not available in a clinic environment. Who may benefit from referral to a different behavioral health service? > A child or youth in acute crisis. Consider referral to Mobile Crisis intervention. > Children and families with needs involving multiple providers or state agencies. Consider referral to ICC. > A child with a disorder that can benefit from outpatient individual or family treatment. How do I make a referral? Referrals can be made directly to the In-Home provider or the child may access In-Home therapy through ICC or outpatient therapy. For more specific information about how to access these services on behalf of a youth enrolled in a MassHealth managed care plan contact the plan directly. Contact numbers for the plans are listed at the end of this section. For a list of the common network of In-Home providers selected by all MassHealth’s Managed Care entities, see Appendix A. For additional providers selected for MBHP’s “extended network”, also see Appendix A. The most up-to-date information on the In-Home Therapy provider network can also be found on the website of the appropriate MassHealth Managed Care entity or by calling the Managed Care entity. E. Mobile Crisis Intervention (starting June 30, 2009) Mobile Crisis Intervention is the youth (under the age of 21) -serving component of an emergency service program (ESP) provider. Mobile Crisis Intervention will provide a short- term service that is a mobile, on-site, face-to-face therapeutic response to a youth experiencing a behavioral health crisis for the purpose of identifying, assessing, treating, and stabilizing the situation and reducing immediate risk of danger to the youth or others consistent with the youth’s risk management/safety plan, if any. This service is provided 24 hours a day, 7 days a week. The service includes: A crisis assessment; development of a risk management/safety plan, if the youth/family does not already have one; up to 72 hours of crisis intervention and stabilization services including: on-site face-to-face therapeutic response, psychiatric consultation and urgent psychopharmacology intervention, as needed; and referrals and linkages to all medically necessary behavioral health services and supports, including access to appropriate services along the behavioral health continuum of care. For youth who are receiving Intensive Care Coordination (ICC), Mobile Crisis Intervention staff will coordinate with the youth’s ICC care coordinator throughout the delivery of the service. Mobile Crisis Intervention also will coordinate with the youth’s primary care physician, any other care management program or other behavioral health providers providing services to the youth throughout the delivery of the service. Who is likely to benefit? A child with MassHealth who is in a behavioral health crisis and who is likely, without intervention, to escalate in a way that would pose a risk of harm to themselves or others. If in doubt, call the Mobile Crisis Intervention team and consult with the team on whether they should intervene. Who may benefit from a different service? If a child is in treatment he or she may have a Risk Management/Safety Plan which may identify other steps prior to calling Mobile Crisis. Note that Mobile Crisis Intervention is only for a child/youth on MassHealth. A person who does not have MassHealth should be triaged through the 800 number on the back of the health insurance card or sent to the local emergency services program or hospital emergency room. If the child/youth is an acute safety risk to self or others and the risk cannot be safely managed in the current setting, call 911. How do I make a referral? Mobile Crisis Intervention is provided by the Emergency Service Provider (ESP) in the region. See the list of ESPs in Appendix A. F. Additional new MassHealth-covered services can be accessed through outpatient therapy, In-Home therapy or Intensive Care Coordination, as part of the youth’s Individual Care Plan (ICP) or treatment plan (for Outpatient or In- Home Therapy). > Family Support and Training (Starting June 30, 2009) Family Support and Training is a service that provides a structured, one-to-one, strength-based relationship between a Family Support and Training Partner and a parent/caregiver. The purpose of this service is for resolving or ameliorating the youth’s emotional and behavioral needs by improving the capacity of the parent /caregiver to parent the youth so as to improve the youth’s functioning as identified in the outpatient or In-Home Therapy treatment plan or Individual Care Plan (ICP), for youth enrolled in Intensive Care Coordination (ICC), and to support the youth in the community or to assist the youth in returning to the community. Services may include education, assistance in navigating the child serving systems (child welfare, education, mental health, juvenile justice, etc.); fostering empowerment, including linkages to peer/parent support and self-help groups; assistance in identifying formal and community resources (e.g., after-school programs, food assistance, summer camps, etc.) support, coaching, and training for the parent/caregiver. In ICC, the care coordinator and Family Support and Training Partner work together with youth with SED and their families while maintaining their discrete functions. The Family Support and Training Partner works one-on-one and maintains regular frequent contact the parent(s)/caregiver(s) in order to provide education and support throughout the care planning process, attends CPT meetings, and may assist the parent(s)/ caregiver(s) in articulating the youth’s strengths, needs, and goals for ICC to the care coordinator and CPT. The Family Support and Training Partner educates parents/ caregivers about how to effectively navigate the child-serving systems for themselves and about the existence of informal/community resources available to them; and facilitates the parent’s/caregiver’s access to these resources. Family Partners are offered to families as part of Intensive Care Coordination. > In-Home Behavioral Health Services – Starting October 1, 2009 In-Home Behavioral Health Services offers valuable support to children and youth with challenging behaviors that get in the way of everyday life. Services are provided by a behavioral health provider, such as a therapist, who is skilled in understanding and treating difficult behaviors in children and youth. The provider works closely with the child and family to create a specific behavior plan to improve the child’s functioning. The provider may also work as a team with a skilled paraprofessional called a behavioral management monitor. The monitor works with the child and family to implement the child’s behavior plan. In-Home Behavioral Health Services can be provided in places where the child is located, including home, school, childcare centers and other community settings. > Therapeutic Mentoring Services – Starting October 1, 2009 A therapeutic mentor works one-on-one with a child or youth who, because of their behavioral health needs, require support and coaching to learn social skills that will allow them to do well in typical, normative environments. These skills may include better ways of communicating with other children and adults, dealing with different opinions and getting along with others. The therapeutic mentor works with the child to achieve goals in a treatment plan written by an outpatient therapist, In-Home Therapy Services provider or Intensive Care Coordination (ICC) team. The mentor is supervised by a behavioral health clinician and can work with a child in his or her home, school, or other social and recreational setting. For families and youth who may need or benefit from these services, social workers should consider facilitating a referral process with the out-patient provider, in-home therapist, or ICC team. For more specific information about how to access these services on behalf of a youth enrolled in a MassHealth managed care plan contact the plan directly. Contact numbers for the plans are listed at the end of this section. G. Current MassHealth Community-Based Services (in addition to the New Services) The following are other community-based (e.g. non-24 hour) behavioral health services that are available to youth enrolled in MassHealth. This is not meant to be an exhaustive list of available benefits but an overview of behavioral health services that are available in addition to the new MassHealth services described earlier in this document. ? Outpatient Behavioral Health Services: Outpatient services include individual, family, and group therapies, as well as medication evaluation and monitoring. Outpatient services can be provided in an office, clinic environment, a home, school, or other location. Outpatient services can be used to treat a variety of behavioral health and/or substance abuse issues that significantly interfere with functioning in at least one area of the youth’s life (e.g., familial, social, occupational, educational). Outpatient is the least intensive level of care available to youth. ? Community Support Programs (CSPs): Provide an array of services delivered by a community-based, mobile, multidisciplinary team of paraprofessionals. CSP services are appropriate for youth who have behavioral health issues challenging their optimal level of functioning in the home/community setting. These services are designed to be maximally flexible in supporting youth who are unable to independently access and sustain involvement with needed services. Services may include: assisting youth in enhancing their daily living skills; case management, skill building, developing a crisis plan; providing prevention and intervention; and fostering empowerment and recovery, including linkages to peer support and self-help groups. NOTE: As of October 1, 2009, CSP for youth under 18 will be replaced by the new community based behavioral health services, described earlier in this document. Youth 18 through 20 will have access to both CSP services as well as the new community based behavioral health services. ? Structured Outpatient Addiction Program (SOAP): SOAP is a short-term, clinically intensive, structured day and/or evening substance abuse service. SOAP can be used by youth, including pregnant youth, who need outpatient services, but who also need more structured treatment for substance abuse. SOAPs provide multidisciplinary treatment to address the sub-acute needs of youth with addiction and/or co-occurring disorders, while allowing them to maintain participation in the community, continue to work or attend school, and be part of family life. ? Partial Hospitalization Program is a nonresidential treatment program that may or may not be hospital-based. The program provides clinical, diagnostic, and treatment services on a level of intensity equal to an inpatient program, but on less than a 24-hour basis. These services include therapeutic milieu, nursing, psychiatric evaluation and medication management, group and individual/family therapy, psychological testing, vocational counseling, rehabilitation recovery counseling, substance abuse evaluation and counseling, and behavioral plans. How Do I Make a Referral? For more specific information about how to access these services on behalf of a youth enrolled in a MassHealth managed care plan contact the plan directly. To locate a provider for youth NOT enrolled in a MassHealth Managed Care Plan, please call: MassHealth Customer Service 1-800-841-2900: TTY: 1-800-497-4648. For youth who ARE enrolled in a MassHealth Managed Care Plan, please call: ? Boston Medical Center (BMC) HealthNet Plan 1-888-566-0010 (English and other languages) 1-888-566-0012 (Spanish) TTY: 1-800-421-1220 ? Fallon Community Health Plan 1-800-341-4848 TTY: 1-877-608-7677 ? Health New England (HNE) 1-800-786-9999 (TTY: 1-800-439-2370) ? Neighborhood Health Plan 1-800-462-5449 TTY: 1-800-655-1761 ? Network Health 1-888-257-1985 TTY: 617-888-391-5535 ? Primary Care Clinician (PCC) Plan 1-800-841-2900 TTY: 1-800-497-4648 ? Massachusetts Behavioral Health Partnership 1-800-495-0086 TTY: 617-790-4130 ? Beacon Health Strategies 1888-217-3501 TTY:1-866-727-9441 Section 2 Department of Youth Services Protocols DYS Strategic Direction on Children’s Behavioral Health The Department of Youth Services is one of five Executive Office of Health and Human Services agencies leading the development and implementation of the Children’s Behavioral Health Initiative (CBHI). With its goal of bringing multiple systems together to best meet the needs of children and families, the CBHI is an integral component of the Department’s strategic effort to promote positive change in the lives of youth committed to our custody. Positive Youth Development, an approach that emphasizes and builds on the strengths of an individual and their family, provides the framework for all DYS services. In 2009, DYS restructured its community service delivery system. The overarching goal of the new Community Services Model is to go beyond accountability and recidivism reduction and to help DYS youth thrive as adolescents and young adults. The model places the emphasis on serving and supervising youth on an individualized basis in the context of their families and their communities. This commitment is reflected in the CBHI’s focus on engaging families as true partners in the development of a meaningful plan of action that best meets their child’s needs for success. When families are actively involved with professionals and collaborate as a team to discover their strengths, positive youth development can emerge. At its core, the new Community Services Model calls for a framework to support a case management team by adding clinical, family, resource, site support and clerical elements to the casework team. While clients are assigned to a primary caseworker responsible for all of the coordination and delivery of services, the community case management team will work in a coordinated fashion to insure that the array of service needs are met and maintained. This array may include service connections in the areas of behavioral health, medical care, education and employment. It may also include connecting youths and their families to mentoring, recreation, civic engagement activities, housing and family supports. And, finally, it will include accountability, supervision and attention to personal safety issues of the client. The Community Services Model envisioned builds on the community supervision model employed successfully by DYS over the past ten years and represents a further evolution of that model. The core features of the model - increased contact and engagement with DYS youth by caring, responsible adults, emphasis on pro social development, building life skills and social competencies, community connectedness, service access, support and supervision - are maintained. The changes build on improved Departmental practices in assessment and residential treatment and programming. They represent a merging of valuable insight and input from our juvenile justice service providers, our staff, and experts from the field of juvenile justice with lessons learned from the past model and an emerging body of promising practices in directly related and relevant fields. The goal is a team that delivers high quality, culturally responsive services and supports; that build on the strengths and compensates for the deficits of the youth and families served by the Department; and in a manner that produces positive results for DYS youth, their families, and their communities. Identifying Behavioral Health Needs Among Its Committed Population Background When the Juvenile Court commits adjudicated juveniles to DYS custody, DYS performs a comprehensive 30-45 day assessment of all newly committed youth, in a DYS Assessment program. As part of the comprehensive 30-45 day assessment of care needs, the DYS Clinician conducts a comprehensive behavioral health assessment, using an array of standard assessment tools and conducts a full case history including home visits, meetings with the family, information-gathering on trauma history, early neurological development, and educational testing to perform a risk-needs analysis for, among other areas, substance abuse, psychological function, and offense behavior. The Child and Adolescent Needs and Strengths tool (CANS) is a standard part of the 30-45 DYS assessment process for newly committed youth. All DYS clinicians are trained in the use of the CANS and all licensed clinicians will be required to be certified in the use of the CANS. Only licensed DYS clinicians can administer CANS. License-eligible clinicians who are trained and certified in CANS may assist in completing the CANS during a DYS assessment and prior to community placement under the direction of a licensed clinician. Prior to release to the community, a DYS clinician updates the CANS as part of the DYS pre-release care planning process, to ensure continuity of care with MassHealth providers. Accessing MassHealth for Committed Juveniles Each newly committed juvenile is enrolled in MassHealth and may choose to enroll in MassHealth's Primary Care Clinician Plan or one of MassHealth's Managed Care Health Plans. If the youth or their Legally Authorized Representative does not make a choice, the juvenile will automatically be enrolled in the Massachusetts Behavioral Health Partnership for their behavioral health care and will receive medical services through MassHealth's fee-for-service network. Identifying the Most Appropriate Community Based Behavioral Health Service ? During the DYS pre-release process, the DYS Clinician will draw on the results of the updated clinical assessment (including CANS). The DYS Caseworker and DYS Clinician will talk with the parent or legal guardian and the youth about the relevant options for behavioral health services, and which service(s) might best fit the behavioral health needs of the youth and family, and help support the youth to reside safely in the community. The Caseworker and Clinician will discuss the appropriateness of a referral to Intensive Care Coordination (ICC) or other CBHI services. ? With appropriate consent, the DYS Caseworker and clinician will then arrange for a referral to the local provider, including a Community Service Agency (CSA) providing additional follow-up as needed to ensure an initial intake and service assessment occurs. ? DYS does not have legal custody over its committed population. The parent or legal guardian decides which behavioral health services best meet the needs of their child. However, DYS is statutorily authorized to determine and establish the conditions under which a youth is released to the community, to enforce compliance with those conditions and to revoke the grant of liberty afforded the youth based on non compliance with those conditions of release. The Department does this with the welfare and safety of the youth and the community in mind. DYS does currently and will continue to make every effort to actively engage the youth and their family in the determination of those conditions of release. For example, DYS often mandates treatment participation as a "condition" of release to the community. This is recorded on the youth's "Grant of Conditional Liberty (GCL)". DYS may require a youth to participate in wraparound services and other CBHI services or to continue substance abuse treatment begun in residential programs in the community, as one of the conditions for release to the community. Providing Referrals Background After a stay in a hardware secure or staff secure residential treatment facility, youth return to the community with a Grant of Conditional Liberty and ongoing supervision and support through a Community Re-entry Center. The Community Re-entry Center does not provide any direct treatment services but maintains relationships with local service providers and the regional CSA. The DYS Case Worker draws on the services provided by community-based providers to support the youth. Once the youth has returned to the community, the DYS Case Worker at the Community Re-Entry Center is responsible to support the youth and family’s participation in behavioral health services. For MassHealth-eligible children: ? During the pre-release process, the DYS Caseworker, in collaboration with the DYS Clinician, is responsible for identifying and making referrals to appropriate behavioral health services. Youth whose updated CANs identifies the presence of a serious emotional disturbance should be considered for referral for ICC services. ? The referral process for all behavioral health services is as follows: 1. Share information about the service with the parent or guardian and the youth (especially for youth making his or her own treatment decisions). 2. With appropriate consent, support the parent (or youth) in seeking services. This can be accomplished by offering provider contact information, or actively facilitating a phone call or meeting with the provider. ? For referrals to Intensive Care Coordination, the DYS Caseworker and DYS clinician will help the family identify the Community Service Agency (CSA) in the geographic area to which the child is returning, and also inform the family of any specialized CSAs serving their region. (See attached list.) A family may request Family Support and Training (through a Family Partner) in conjunction with the referral. The family may make this request to the provider independently, or the DYS caseworker or casework manager may assist them by facilitating a phone call or meeting with the treatment provider. ? For referrals to In-Home Therapy and all other MassHealth Behavioral Health services, the Caseworker and DYS clinician will help the family identify providers in their community. For more information about how to access these services on behalf of a youth enrolled in a MassHealth managed care plan DYS can contact the managed care plan directly. A list of the plans and contact numbers and websites are Attached in Appendix A. ? If a youth is living apart from his parents or guardian, the youth may obtain Intensive Care Coordination services without parental consent under the following circumstances. Massachusetts General Law Ch. 112 s. 12F states in part: “Any minor may give consent to his medical or dental care at the time such care is sought if (i) he is married, widowed, divorced; or (ii) he is the parent of a child, in which case he may also give consent to medical or dental care of the child; or (iii) he is a member of any of the armed forces; or (iv) she is pregnant or believes herself to be pregnant; or (v) he is living separate and apart from his parent or legal guardian, and is managing his own financial affairs.” In this instance, the eligible young person may consent to Intensive Care Coordination services, and ICC Care Coordinator will work directly with the youth to develop the Care Planning Team. As part of the referral process, DYS will provide assistance in documenting that such a youth is eligible to give consent to behavioral health care under the conditions of MGL Ch 112. Note: Youth residing in hardware-secure DYS facilities are not eligible for MassHealth services until they leave the facility. For Referrals to Mobile Crisis Intervention Service For MassHealth enrolled Youth Living in the Community ? Prior to discharge, the DYS Caseworker and DYS clinician will provide the family with the written contact information for Mobile Crisis Intervention service and inform the family that Mobile Crisis Intervention Service will come to locations in the community where the youth is located, including home, school or other community setting. The family will be urged to call the Mobile Crisis Intervention Service in their area if the youth is in a crisis. ? The DYS Case worker should support the family in making this call if he/she is contacted by the family. DYS case workers will have the number of their local Mobile Crisis readily available. For MassHealth enrolled Youth in Staff Secure Treatment Facilities: ? As the children-serving arm of the Emergency Services Program to be used for MassHealth eligible youth under 21, Mobile Crisis may be called by DYS staff in the event of a behavioral health crisis. ? The phone number of the Mobile Crisis in the area will be posted in appropriate locations in the facility. ? DYS clinicians are responsible for delivering behavioral health intervention services in DYS staff secure facilities. The Mobile Crisis Intervention provider will be accessed when additional intervention including level of care assessment is required. Referrals to MassHealth Behavioral Health Services for MassHealth-enrolled DYS Youth Residing in the Community ? The DYS case worker is responsible for identifying and addressing the evolving needs of a youth living in the community under a grant of conditional liberty. These needs and related services are added to the DYS Service Plan as the needs emerge, and are reviewed and revised every 6 months. For DYS youth in community placement, the DYS Caseworker will identify, address and document each youth’s behavioral health needs in the youth's Individual Service Plan (ISP) and Relapse Prevention Plan (RPP). The caseworker will then facilitate access to those ISP services. ? If the behavioral health needs of a youth change while the youth is living in the community, the DYS case worker will: o Consult with the DYS Community Clinical Coordinator and with any behavioral health provider(s) treating the youth, and devise an appropriate intervention plan. This may include a meeting to review and revise the youth's ISP and RPP and referrals to additional behavioral health services and supports, as needed. o If the youth is not currently receiving behavioral health services, refer the youth to a MassHealth behavioral health provider for a behavioral health assessment and appropriate services intervention. o Document changes in the youth’s behavioral health needs and related services in the youth’s ISP and RPP. Expected MassHealth Provider Response to Referrals of DYS Clients ? For Referrals to Intensive Care Coordination o Within 24 hours of referral to ICC, the ICC provider will make telephone contact with the youth, parent or guardian to offer a face-to-face interview. o A face-to-face interview with the youth and/or family will be offered within three (3) calendar days of the referral to begin a comprehensive home-based assessment. o The comprehensive home-based assessment inclusive of the CANS must be completed within 10 calendar days of the date on which consent for ICC was obtained. o The ICC care coordinator and DYS referral source will be expected to confer to discuss the reason for referral (with proper consent as required by law). As part of the comprehensive home-based assessment, the ICC care coordinator is expected to secure youth, parent or guardian authorization and to convey it by fax, mail or hand delivery to DYS and the providers with whom they want to speak. o The care coordinator will convene the youth’s Care Planning Team within 28 calendar days of the youth, parent or guardian’s consent to treatment. ? For Referrals to In-Home Therapy o The In-Home Therapy provider responds telephonically to all referrals within one business day. o During daytime operating hours (8 a.m. to 8 p.m.), the In-Home Therapy Services provider responds by offering a face-to-face meeting with the youth or family seeking services within 24 hours. ? General o If the child or youth does not meet the medical necessity criteria for the service, or if the youth and family do not wish to participate, the behavioral health provider is expected to discuss this with the DYS Caseworker and provide a referral to other services, if appropriate. Ensuring Continuity of Care ? For youth in a DYS staff-secure facilities who are eligible for Intensive Care Coordination or In-Home Therapy, enrollment in ICC may occur no more than 180 days prior to discharge from the residential/secure setting. ? Once the family and provider agree on a specific community-based behavioral health service, the provider will be named in the DYS Individual Service Plan. ? During the pre-release process, if the family decides that ICC is an appropriate service, and the ICC service is medically necessary, the DYS clinician and the DYS case worker will meet with the Care Coordinator and family to document a planned transition to ICC. Where possible, DYS will allow ICC care coordinators and family partners to hold care planning meetings on site at DYS staff-secure facilities during this transition. ? With the permission of the parent/guardian, the DYS clinician will provide a printed copy of the CANS to the ICC provider as part of the referral process. ? The DYS Caseworker and DYS clinician will participate in one or more transition meetings to ensure continuity of care and a smooth transition planning into community- based behavioral health services. ? The DYS Caseworker responsible for working with the youth when s/he returns to the community will participate in the transition planning process with the DYS clinician, the family, and potential community-based behavioral health providers to support a smooth transition to the community. For youth enrolled in ICC, the DYS Caseworker will represent DYS on the youth’s care planning team, from commitment to discharge from the Department. Note: Youth residing in hardware-secure DYS facilities are not eligible for MassHealth services until they leave the facility. DYS Participation In ICC Care Planning Team ? DYS’s Goal for ICC: DYS’s goal is to work collaboratively as part of the Care Planning Team with the shared mission of keeping the youth safely in the community. ? DYS Representation on Care Planning Teams: DYS case workers will serve on the Care Planning Team for the youth on their case loads and regularly attend Care Planning Team meetings. ? DYS Caseworker Role: The DYS case worker is expected to play an active role in the ICC Care Planning Team with the goal of keeping the family engaged and the youth safely in the community. The DYS case worker is responsible for bringing the concerns of DYS to the ICC Care Planning Team so that a collaborative effort can be made by the Team to adequately address all DYS concerns and to try to come to a shared plan of action. All ICC team members are expected to comply with all laws and regulations governing confidentiality of all information regarding its clients whether protected health information, CORI, or other confidential data. ? DYS Case Worker Service Plan: The DYS case worker will regularly update the youth DYS Individual Service Plan within the rules and regulations of DYS regarding such plans to reflect the agreements and plans defined in the ICC Care Planning Team, in an effort to ensure that the two plans, the youth DYS Individual Service Plan from DYS and the ICC Individual Care Plan are consistent and integrated to the greatest extent possible. ? ICC Risk Management/Safety Plan: The Care Planning Team, including the DYS case worker, will develop an integrated plan for dealing with potential risk, including contingencies related to revocation of the youth under the youth’s DYS Individual Service Plan. The ICC Risk Management/Safety Plan will be referenced in the DYS Individual Service Plan. However, nothing in the ICC Risk Management/Safety Plan limits DYS’ statutory authority to determine and establish the conditions under which a youth is released to the community, to enforce compliance with those conditions and to revoke the grant of liberty afforded the youth based on non compliance with those conditions of release. DYS Revocation of a Grant of Conditional Liberty for a youth in ICC ? DYS Legal responsibility: The legal mandates and mission of DYS are unchanged by the ICC process. ? Decision to revoke grant of conditional liberty: DYS is solely responsible for granting and revoking a grant of conditional liberty of youth committed to DYS, however, the DYS caseworker will explore the options with the Care Planning Team prior to revocation whenever possible. To the extent possible, plans and contingencies should be reflected in the ICC Risk Management/Safety plan, developed in advance of a crisis. ? Communication about revocation with ICC Care Coordinator and Care Planning Team: In the event that DYS revokes a youth’s grant of conditional liberty for either a short or long term period, the ICC care coordinator will be notified by the DYS Case Worker within 1 day of any revocation which results in the youth’s removal by DYS from the community, unless such communication cannot be made due to safety concerns for the youth. The ICC care coordinator is responsible for communicating the notification of the revocation to the rest of the team and immediately convening the Team, including its DYS representative, to discuss the implications of this decision for ongoing care and treatment. ? Care Planning Team Role After Revocation: For short-term revocation, the ICC team will continue to meet and to plan the youth’s transition back into the community. In the event of a long-term revocation lasting more than 6 months, the ICC team will convene for a final meeting as soon after revocation as possible for transition planning as well as discussing anticipated issues for the pre-release process. If a youth wishes to receive ICC upon discharge, a new request for ICC services must be made as part of the pre-release process. If the youth or parent/guardian requests to work with the same Care Coordinator or Family Partner, the Community Service Agency will make reasonable efforts to assign the requested staff. Readmission to ICC may occur no more than 180 days prior to discharge from the staff-secure facility. ? DYS youth who are hospitalized or placed in a psychiatric residential treatment facility while in ICC: In the event an ICC-enrolled youth requires inpatient hospitalization or placement in a residential treatment facility, the CPT may continue to meet monthly or as needed in order to plan for return to the community. For youth whose hospitalization or placement exceeds 6 months, ICC will need to convene a final meeting to transition from ICC services. Re: enrollment to ICC may occur no more than 180 days prior to discharge from the hospital or psychiatric residential treatment facility. What Happens When A Youth Enrolled in ICC Is Newly Committed to DYS? Background ? When ICC enrolled youth are newly committed to DYS, the ICC Care Coordinator will convene the youth’s Care Planning Team, including appropriate DYS staff. The purpose of the meeting is to provide DYS with recent assessment information, including the youth’s progress toward meeting Individual Care Plan goals, to inform DYS’ comprehensive behavioral health assessment of the youth. ? As part of the pre-release process, the DYS clinician will make a new referral to ICC as described above. If ICC is medically necessary, the family may request the same care coordinator or family partner as they had previously, and the CSA will make its best effort to accommodate that request, but is not under obligation to do so. Trainings To Ensure Coordination Between DYS and Intensive Care Coordination ? DYS Staff Training: All DYS District Managers, Case Worker Supervisors, Case workers, clinicians and Court Liaisons and other designated DYS Community provider staff will receive training in the Wraparound care planning process and in these protocols. This training will also be offered on an ongoing basis for new DYS staff members. The purpose of the Wraparound training is to understand the process of collaborative care planning, and Systems of Care values and principles and the various roles of DYS caseworkers, supervisors and area directors in the process. ? CSA Training: Care coordinators and family partners will receive training on the DYS system and how it works, collaborative approaches to working with DYS, including the needs of transition-aged youth, the care coordination needs of court-involved youth, and how DYS’s mandate may impact the care planning process. DYS staff will help deliver this aspect of CSA training. DYS Participation in Local System of Care Committees ? The DYS Regional Director or their designee will represent the Department at each of 29 Local System of Care committees. ? When issues arise within the Local System of Care committee meetings of concern to the DYS representative, these issues will be referred to the DYS Regional Director and, as appropriate, to the DYS representative on the CBHI Interagency Team at the State level. Youth in Detention/Pre-trial DYS staff will provide youth and their parents or guardians with information regarding CBHI services. The decision about whether or not to pursue such services will be solely that of the youth and his/her parents or guardian. These new services are expected to become available between June 30 and November 1, 2009. However, MassHealth needs the approval of the federal Medicaid program in order to pay for these services. MassHealth has received approval for Intensive Care Coordination and it awaiting approval for the other services. 1 Department of Youth Services Guide to New MassHealth Behavioral Health Services & Protocols March 2011