This Oregon rule establishes certification and operating standards for Intensive In-Home Behavioral Health Treatment (IIBHT), a community-based, multidisciplinary mental health treatment program for youth and young adults under age 21 (and EPSDT/YSHCN-eligible individuals) and their families. Providers must hold a current Certificate of Approval for outpatient mental health services before applying to render IIBHT services. The rule sets minimum service delivery requirements including individual and family therapy, psychiatric services, skills training, peer-delivered services, case management, care coordination, and 24/7 crisis response. All services are delivered in home, school, or other community settings rather than facility-based settings.
View official sourceOregon Health Authority Health Systems Division: Behavioral Health Services - Chapter 309 Division 21 COMMUNITY BASED SERVICES FOR YOUTH AND YOUNG ADULTS 309-021-0100 IIBHT Purpose and Scope (1) The Intensive In-Home Behavioral Health Treatment (IIBHT) is a community based, multidisciplinary mental health treatment program for youth and young adults under the age of 21 and anyone covered under Early and Periodic Screening. Diagnostic and Treatment (EPSDT) or Youth with Special Health Care Needs (YSHCN) and their families. IIBHT offers a menu of therapeutic services and supports for youth , young adults and their families delivered in a community-based setting. The intent of IIBHT is to work collaboratively with youth, young adults and their families to address complex mental health concerns, reduce emergency department use, avoid out of home placement or facility-based treatment where possible, and support youth, young adults and their families when returning home from out of home placement or facility-based treatment. (2) IIBHT Providers shall have program staff that includes Licensed Medical Providers (LMP), Qualified Mental Health Professionals (QMHP), Qualified Mental Health Associates (QMHA) and Peer Support Specialists available and sufficient to meet the individual needs and preferences of the youth, young adults, and their families enrolled in services. (3) IIBHT providers shall coordinate care with internal and external partners as needed to support the mental health needs and supports of the youth/young adult and their family. (4) IIBHT Services shall include, at a minimum, the following types of services: (a) Child Psychiatric Services provided by: (A) A Board Eligible or Certified Child and Adolescent Psychiatrist; or (B) A Psychiatric Mental Health Nurse Practitioner (PMHNP) with at least 3 years of experience working with youth, young adults, and families. (b) Skills training; (c) Individual therapy; (d) Family therapy; (e) In-home Proactive Support and Crisis Response available 24 hours each day; (f) Case Management (g) Peer Delivered Services: (A) Family Support Specialists; and (B) Youth Support Specialists. (h) Care Coordination; and (i) 90 Day Treatment Review Meetings (5) All providers must operate in compliance with these rules. These rules create the minimum service delivery standards for services and supports delivered by providers certified by the Behavioral Health Division of the Oregon Health Authority. (6) Before a provider can apply to render IIBHT services, providers must hold a current Certificate of Approval for outpatient mental health services in accordance with OAR Chapter 309, Division 008 (309-008-0100 – 309-008-1600) Certification of Behavioral Health Treatment Services. Statutory/Other Authority: ORS 413.042, 430.640 & 430.705 Statutes/Other Implemented: ORS 430.010, 430.205 & 430.708 History: BHS 3-2025, adopt filed 02/27/2025, effective 03/01/2025 309-021-0110 IIBHT Definitions (1) “Authority” means the Oregon Health Authority. (2) “Behavioral Health Treatment” means treatment for mental health, substance use disorders, and problem gambling. (3) “Best Practice Risk Assessment” has the meaning given that term in OAR 309-023-0110. (4) “Care Coordination” means a process-oriented activity to facilitate ongoing communication and collaboration to meet multiple needs. Care coordination includes facilitating communication between the person or family served, the family, natural supports, community resources, and involved providers and agencies; organizing, facilitating, and participating in team meetings; and providing for continuity of care by creating linkages to and managing transitions between levels of care and transitions for young adults in transition to adult services. (5) "Case Management” means the services provided to assist individuals who reside in a community setting or are transitioning to a community setting in gaining access to desired medical, social, educational, entitlement, and other applicable services. (6) “Certificate of Approval” means the document issued by the Authority that identifies and declares certification of a provider pursuant to OAR chapter 309, division 008. (7) "Clinical Supervision" means oversight by a qualified clinical supervisor of the rendering of physical health, substance use, problem gambling, and mental health services and supports, according to these rules, including ongoing evaluation and improvement of the effectiveness of those services and supports. (8) "Clinical Supervisor" means program staff qualified to oversee and evaluate the rendering of physical health, substance use, problem gambling, or mental health services and supports. (9) “Coordinated Care Organization (CCO)” means a corporation, governmental agency, public corporation, or other legal entity that is certified as meeting the criteria adopted by the Authority under ORS 414.625 to be accountable for care management and to provide integrated and coordinated health care for each of the organization’s members. (10) "Crisis" means either an actual or perceived urgent or emergent situation that occurs when an individual’s stability or functioning is disrupted, and there is an immediate need to resolve the situation to prevent a serious deterioration in the individual’s mental or physical health or to prevent referral to a significantly higher level of care or death. (11) "Crisis and Safety Plan" means an individualized document developed by the youth/young adult and their family in collaboration with the IIBHT team to address potential crises that could occur for the youth and their family, and to ensure everyone's safety. It shall include 24-hour, 7-days-a-week response; formal, informal, and natural supports; back-up care, as applicable; details leading to crises; successful strategies that have worked in the past; and strength-based strategies that prevent escalation and maintain safety (12) "Diagnosis" means the principal mental health, substance use, or problem gambling diagnosis listed in the Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM-5-TR). The diagnosis is determined through the assessment and any examinations, tests, or consultations suggested by the assessment and are medically necessary reason for services. (13) “Division” means the Behavioral Health Division of the Oregon Health Authority, or its designee. (14) “Entry” means the act or process of acceptance and enrollment into services regulated by this rule. (15) "Family" means the biological or legal parents, siblings, other relatives, foster parents, legal guardians, spouse, domestic partner, caregivers, and other primary relations to the individual whether by blood, adoption, or legal or social relationships. Family also means any natural, formal, or informal support persons identified as important by the individual. (16) "Family Support" means the provision of peer-delivered services to people defined as family to the individual. It includes support to caregivers at community meetings, assistance to families in system navigation and managing multiple appointments, supportive home visits, peer support, parent mentoring and coaching, advocacy, and furthering efforts to develop natural and informal community supports. (17) "Family Support Specialist” means an individual certified and listed on the registry as a Family Support Specialist in accordance with ORS 410-180-0305, and who has completed specialized training approved by the Authority. A Family Support Specialist is a formal member of the IIBHT team whose role is to support the family (18) “In-Home” means that IIBHT services shall be delivered at times and locations that are convenient to the youth and their family and IIBHT staff are available to provide services in the home, school, or other community setting, as specified by the individual and family. (19) “Incident Report” means a written description of any incident. (20) “Individual” means any individual being considered for or receiving services and supports regulated by these rules. (21) "Informed Consent for Services" means that the service options, risks and benefits have been explained to the individual and guardian, if applicable, in a manner that they comprehend, and the individual and guardian, if applicable, have consented to the services on, or prior to, the first date of service. (22)“Intensive In-Home Behavioral Health Treatment (IIBHT)” means an intensive, community-based level of care for youth and young adults under the age of 21, with complex mental health needs who requiring multiple weekly, mental health services and supports to maintain in the community. They may be at risk for an out of home placement or may be stepping down from a higher level of care IIBHT includes access to an array of services including individual and family therapy, case management, psychiatric services, skills training, peer-delivered services, and proactive 24 hours 7 days a week crisis response. A Certificate of Approval from the Oregon Health Authority is required to render IIBHT services to eligible youth and families. (23) “Intensive In-Home Behavioral Health Treatment (IIBHT) team” means any staff member assigned by the Certified IIBHT Provider that has been identified to provide services and supports as outlined in the service plan to a youth, young adult and/or their family while enrolled in IIBHT services (24) "Level of Care" means the type, frequency, and duration of medically necessary and medically appropriate services provided from the most integrated setting to the most restrictive and intensive inpatient setting (25) "Licensed Medical Practitioner (LMP)” means a person who meets the following minimum qualifications as documented by the Local Mental Health Authority (LMHA) or designee: (a) Physician licensed to practice in the State of Oregon; (b) Nurse practitioner licensed to practice in the State of Oregon; or (c) Physician's assistant licensed to practice in the State of Oregon; (d) Whose training, experience, and competence demonstrate the ability to conduct a medical exam, a mental health assessment and provide medication management; and (26) “Natural Supports” means individuals in the youth and family’s own community, social, cultural or spiritual networks, such as friends, extended family members, neighbors, and other individuals as identified by the youth and family, providing supports, who are not financially compensated for their time. (27) “Peer” means program staff supporting an individual or the individual's family member who has similar life experience, either as a current or former recipient of mental health or substance use, problem gambling, or mental health services, or as a family member of an individual who is a current or former recipient of substance use, problem gambling, or mental health services. (28) “Peer-Delivered Services” are community-based services and supports provided by peers, peer support specialists, and peer wellness specialists to individuals or family members with similar lived experience. These services are intended to support individuals and families to engage individuals in ongoing treatment and to live successfully in the community. (29) “Peer Support Specialist (PSS)” means a qualified program staff providing peer-delivered services to an individual or family member with similar life experience under the supervision of a qualified clinical supervisor and a qualified peer-delivered services supervisor as resources are made available. (30) “Proactive Support and Crisis Response” means that youth and their families have 24/7/365 access to program staff via phone support and that a face-to-face response is available to the youth and families as needed to assist the youth and family and prevent unnecessary emergency room visit and law enforcement. Program staff must have access to the youth’s Crisis and Safety Plan and complete the required documentation. (31) "Program" means an organized system of services and supports delivered by a provider designed to address the treatment needs of individuals and families. (32) "Program Staff" means personnel who renders a clinical service or support. Program staff could include, for example, be an employee, contractor, intern, or volunteer who is rendering or assisting with rendering clinical services or supports. (33) “Provider” means an organizational entity or qualified person that is certified or licensed by the Division for the direct delivery of substance use, problem gambling, or mental health services and supports. (34) Psychiatrist" means a physician licensed by the Oregon Medical Board and who has completed an approved residency training program in psychiatry. (35) "Qualified Mental Health Associate (QMHA)” means mental health program staff delivering services under the direct supervision of a QMHP who meets the minimum qualifications as authorized by the LMHA or designee and specified in OAR 309-019-0125. (36) "Qualified Mental Health Professional (QMHP)" means mental health program staff LMP or any other program staff meeting the minimum qualifications as authorized by the LMHA or designee and specified in OAR 309-019-0125. (37) "Risk Assessment" means an evaluation of the level or severity of risk the individual is experiencing and how each interact. (38) "Screening" means the process to determine whether the individual needs further assessment to identify circumstances requiring referrals or additional services and supports. (39) "Service Plan" means a comprehensive plan for services and supports provided to or coordinated for an individual and their family, as applicable, that is reflective of the assessment and the intended outcomes of service. (40) “Service Note” means the written record of services and supports provided, including documentation of progress toward intended outcomes consistent with the timelines stated in the service plan. (41) “Service Record” means the written or electronic documentation regarding an individual and resulting from entry into services, assessment, orientation, services and supports planning, services and supports provided, and transfer. (42) "Services" means those activities and treatments described in the service plan and rendered, that are intended to support the individual's transition to recovery from a substance use disorder, problem gambling disorder, or mental health condition and to promote resiliency and rehabilitative and functional individual and family’s desired outcomes. (43) "Skills Training" means providing information and training to individuals and families designed to assist with the development of skills in areas including but not limited to anger management, stress reduction, conflict resolution, self-esteem, parent-child interactions, personal relationships, drug and alcohol awareness, behavior support, symptom management, accessing community services, and daily living. (44) “Suicide Risk Assessment” means a comprehensive evaluation, usually performed by a clinician, to evaluate suspected suicide risk in an individual, estimate the immediate danger, and decide on a course of treatment. May also be called Risk Assessment. (45) “Suicide Screening” means a procedure in which a validated tool, or protocol is used to identify individuals who may be at risk for suicide. (46) “Supports” means activities, referrals, and supportive relationships designed to enhance the services delivered to individuals and families for the purpose of facilitating progress toward intended outcomes. (47) “Transfer” means the process of assisting an individual to transition from the current services to the next identified setting or ASAM level of care. (48) “Trauma Informed Services” means services that reflect the consideration and evaluation of the role that trauma plays in the lives of people seeking mental health, substance use, or problem gambling services, including recognition of the traumatic effect of misdiagnosis and coercive treatment. Services are responsive to the vulnerabilities of trauma survivors and are delivered in a way that avoids inadvertent re-traumatization and facilitates individual direction of services. (49) "Treatment" means the planned, individualized program of medical, psychological, and rehabilitative procedures, experiences, and activities designed to remediate symptoms of a DSM-5-TR diagnosis. (50) “ Wraparound" means a voluntary and definable care planning process that results in a unique set of community services and supports individualized for a youth and family to achieve a positive set of outcomes. (51) “Youth” is the universal term used to describe all individuals, children, adolescents, and teenagers from birth through the age of 17 enrolled in IIBHT services. (52) “Youth Peer Support Specialist” means an individual certified and listed on the registry as a Youth Peer Support Specialist in accordance with ORS 410-180-0305, and who has completed specialized training approved by the Authority. (53) “Young adults” is the accepted term to describe individuals between the ages of 18 and 20 years of age enrolled in IIBHT services. Statutory/Other Authority: ORS 413.042, 430.640 & 430.705 Statutes/Other Implemented: ORS 430.010, 430.205 & 430.708 History: BHS 3-2025, adopt filed 02/27/2025, effective 03/01/2025 309-021-0120 IIBHT General Requirements (1) Each provider must meet the requirements contained within the following Oregon Administrative Rules (OAR) as applies to the type of service delivered: (a) OAR 309-008 Certification of Behavioral Health Treatment Services (b) OAR 309-019-0110 Provider Policies; (c) OAR 309-019-0115 Individual Rights; (d) OAR 309-019-0125 Specific Staff Qualifications and Competencies; (e) OAR 309-019-0130 Personnel Documentation, Training, and Supervision; (f) OAR 309-019-0135 Entry and Assessment; (g) OAR 309-019-0140 Service Plans and Service Notes; (h) OAR 309-019-0205 Building Requirements in Behavioral Health Programs (i) OAR 309-019-0210 Quality Assessment and Performance Improvement; (j) OAR 309-019-0215 Grievances and Appeals (2) Providers billing Medicaid must meet the requirements contained within the following Oregon Administrative Rules (OAR) as applies to the type of service delivered: (a) OAR Chapter 410, Division 120 Medical Assistance Programs; (b) OAR Chapter 410, Division 172 Medicaid Payment for Behavioral Health Services. (c) OAR Chapter 410 Division 151 Early and Periodic Screening, Diagnostic and Treatment Statutory/Other Authority: ORS 413.042, 430.640 & 430.705 Statutes/Other Implemented: ORS 430.010, 430.205 & 430.708 History: BHS 3-2025, adopt filed 02/27/2025, effective 03/01/2025 309-021-0130 IIBHT Staff Qualifications and Requirements (1) Due to the complex needs of youth and young adults enrolled in IIBHT, IIBHT providers must have policies and procedures in place that address the following: (a) How the agency will ensure that IIBHT staff have access to a QMHP or Clinical Supervisor to provide time sensitive consultation and support, as needed during working hours, outside of their required monthly supervision. (b) How the agency will assess the ongoing training needs of IIBHT staff members and ensure access to trainings during working hours, and include how the agency plans to support the use of evidence based and/or promising practices for complex cases requiring individual and family therapy. (c) How the agency will determine which staff attend IIBHT related meetings, trainings, and the OHA sponsored IIBHT Learning Collaboratives. (2) QMHP Requirements: (a) Qualify as a Qualified Mental Health Professional as defined in OAR 309.019.0150 (b) Participate in weekly IIBHT meetings to review complex cases and review clinical supports and safety plans (c) Have no more than 12 total youth/families assigned per QMHP, at any given time, regardless of serving multiple programs (3) Skills Trainer requirements: (a) Qualify as a Qualified Mental Health Associate as defined in OAR 309.019.0150 (b) Participate in weekly IIBHT meetings to review complex cases, clinical interventions and supports and review crisis and safety plan, as needed (4) IIBHT Youth Support Specialists and Family Support Specialists requirements: (a) Qualify as a Youth Support Specialist or Family Support Specialist as outlined in 309-019-0125 (b) Has obtained certification as a Youth Peer Support Specialists or Family Support Specialist and is listed on the Oregon Health Authority’s Traditional Health Worker Registry within 90 days of hire. (c) Participate in weekly IIBHT meetings to review complex cases and review clinical supports and safety plan (d) Receive supervision from a staff trained in an OHA approved training on Peer Supervision. (5) IIBHT Clinical Supervisor Requirements: (a) Meet qualifications as a mental health clinical supervisor under OAR 309-019-0125 (b) Demonstrate additional competence in: (A) Communication and collaboration within interdisciplinary clinical teams (B) Clinical expertise with individual and family interventions for youth and families experiencing complex dynamics and/or presentations (C) Trauma informed philosophy and practices (D) Adaptation of clinical practices for individuals with intellectual and/or developmental disability (E) Adaptation of clinical practices to address the cultural, racial, and/or ethnic needs of youth and families (c) Utilize t he IIBHT Program and Practice Standards and an OHA approved clinical supervision tool (d) Attend training on supervision of Family Support Specialists and/or Youth Support Specialists through an Oregon Health Authority-approved training. (e) Attend OHA-sponsored quarterly IIBHT Supervisor Learning Collaborative. (f) Provide weekly meetings or group supervision to coordinate treatment supports, review safety plans, and coordinate crisis response between IIBHT staff members. (g) Have access to clinical consultation with an LMP, as needed. Statutory/Other Authority: ORS 413.042, 430.640 & 430.705 Statutes/Other Implemented: ORS 430.010, 430.205 & 430.708 History: BHS 3-2025, adopt filed 02/27/2025, effective 03/01/2025 309-021-0140 IIBHT eligibility criteria (1) IIBHT eligibility for youth and young/adults based on the following eligibility criteria as assessed and documented by a QMHP or LMP with recent and direct experience treating or assessing the youth: (a) Youth and family are experiencing intensive mental health needs which lead to increased conflict and crisis in the home, school and or community; or (b) Youth has a history of traumatic experiences that are impacting their ability to function in multiple domains; or (c)Youth is at risk of psychiatric hospitalization or residential treatment due to intense behavioral health challenges; or (d)Youth is at risk of losing their current living situation due to intense behavioral health challenges; or (e) Youth is transferring back to their home or community from an out of home placement and increased services to support of their mental health are needed for successful transition; or (f) Youth is at high risk of harm to themselves or others; or (g) Youth requires an increased frequency and intensity of services and is exceeding what can be offered in the Outpatient level of care setting; or (h) Other risk factors impacting the safety in the home or community (2) The following additional criteria shall be considered when determining program eligibility for young adults between the ages of 18 and 20 yeas of age: (a) Young adult is living with family; and/or (b) Young adult is under ODHS custody; and/or (c) Young adult is enrolled in high school; and/or (d) Young adult is assessed to be developmentally appropriate for IIBHT (3) IIBHT Services shall include the provision and documentation of the following: (a) Youth/Young adults are considered for IIBHT services without regard to race, ethnicity, gender, gender identity, gender presentation, sexual orientation, religion, creed, national origin, age, intellectual and/or developmental disability, IQ score, or physical disability. (b) IIBHT services shall be available to a youth/young adult in their home, school, or other community environment as determined by the youth/young adult and their family and are offered at times and frequencies that are convenient to the youth/young adult and family as agreed upon in the signed Service Plan. (c) Youth/young adults and their families shall not be required to participate in other services or supports, including Wraparound, in order to receive IIBHT. (d) Youth/young adults shall not be denied for IIBHT services due to lack of biological family involvement or an identified parent/caregiver. IIBHT providers will coordinate services with Oregon Department of Human Services, foster families and other natural supports as appropriate. (e) IIBHT providers may not require a youth/young adult or their family to terminate services with an external behavioral health provider in order to access IIBHT services. (f) IIBHT services shall not be duplicative, unless clinically appropriate and medically necessary and requested by the youth/young adult or their family. If a youth is assigned a Youth Peer Support Specialists through a different program, IIBHT shall not assign another Youth Peer Support Specialist. (g) If a youth/young adult is enrolled in Fidelity Wraparound, the IIBHT QMHP shall coordinate with the Wraparound Care Coordinator assigned to the youth. The Wraparound Care Coordinator shall continue to provide care coordination services for the youth/young adult during the time they are enrolled in IIBHT services. (h) Youth/Youth adults are eligible to receive IIBHT services in congregate care settings including Behavior Rehabilitation Services, Treatment Foster Care, Temporary Placements, and/or Developmental Disability group if the youth/young adult’s behavioral health needs and meets medical necessity and appropriateness for IIBHT. Statutory/Other Authority: ORS 413.042, 430.640 & 430.705 Statutes/Other Implemented: ORS 430.010, 430.205 & 430.708 History: BHS 3-2025, adopt filed 02/27/2025, effective 03/01/2025 309-021-0150 IIBHT Referrals and Admissions (1) IIBHT providers must have policies and procedures in place which outline their process for reviewing and responding to referrals as quickly as possible in order to address the needs of complex youth and young adults in crisis and avoid the need for emergency department use or higher level of care. (2) IIBHT Providers must have policies and procedures in place which outline their response to referrals and admissions in accordance with these rules and for partnering with local hospital emergency departments (EDs) and local school districts to address youth mental health crises and referrals. (3) Providers shall accept completed referrals from mental health outpatient programs, residential treatment facilities, Community Mental Health Programs, Coordinated Care Organizations, Oregon Department of Human Services, youth/young adults and/or their families, and other community partners when accompanied by the following: (a) All referrals must utilize the IIBHT Universal Referral Form provided by OHA; and (b) Include documentation by a QMHP or LMP with recent and direct experience treating or assessing the youth which include clinical justification for this level of care. (4) IIBHT providers shall track all referrals to IIBHT services including at a minimum the date of the referral, approval or denial date, and either the denial reason or estimated date of admission. IIBHT providers will submit documentation to OHA quarterly or as requested. (5) Per the CCO and IIBHT program’s referral policies, the deciding entity shall communicate the determination decision within 5 business days of receipt of an IIBHT referral to the referring party. This determination shall reference appropriate medical necessity and appropriateness standards for acceptance or denial. If there is insufficient information to process the referral, the deciding entity will respond to the referring party requesting the additional information. (6) Youth shall be enrolled into IIBHT services within 14 days of the referral being approved. If the provider is unable to enroll the youth/young adult into IIBHT services within 14 days, the provider must notify their CCO immediately. The CCO shall work with the youth/young adult and their family to: (a)provide ongoing care coordination and support, (b) ensure that interim alternative community-based services are in place, (c) communicate with the IIBHT provider to facilitate IIBHT enrollment as soon as possible to prevent the need for higher levels of care. Statutory/Other Authority: ORS 413.042, 430.640 & 430.705 Statutes/Other Implemented: ORS 430.010, 430.205 & 430.708 History: BHS 3-2025, adopt filed 02/27/2025, effective 03/01/2025 309-021-0160 IIBHT Entry, Assessment and Engagement (1) The IIBHT Entry, Assessment and Engagement process must occur in accordance with OAR 309-019-0135. (2) IIBHT providers shall create and utilize a written entry procedure to ensure youth/young adults and their families are offered an intake in the timeliest manner feasible, consistent with the youth/young adult and family’s presenting circumstances once approved. (3) IIBHT providers shall provide a written description of the IIBHT program which includes at a minimum the available services and supports offered and the treatment review meeting expectations and timelines. (4) IIBHT assessments shall be completed or updated in collaboration with the youth/young adult and their family at the time of entry, prior to development of the service plan (5) A Crisis and Safety Plan shall be developed and approved by the youth/young adult and their family in consultation with the IIBHT team and shall, at a minimum include the provision and documentation of the following: (a) The youth/young adult and family’s definition of crisis; (b) At least one strategy to prevent a crisis situation and at least one strategy to use during a crisis situation; (c) A list of antecedents , warning signs, and recommended de-escalation strategies and supports identified by the youth/young person and their family in consultation with the IIBHT team; (d) Strategies for risk prevention for existing or anticipated safety concerns. This shall include strategies developed through lethal means counseling to help individuals at risk for suicide and their families to reduce access to lethal means, including but not limited to firearms and medications; (e) Strength-based strategies for addressing the youth/young adult and their family’s needs when in crisis; (f) Natural and formal supports approved by the youth/young adults and their family for crisis response; (g) Be updated at the request of the youth/young adult or family, or when clinical circumstances change, including following any placement change, psychiatric crisis, overdose, suicide attempt, police involvement, or other situations identified by the youth/young adult or family; (h) Safety requirements from other child-serving or legal systems; (i) Be culturally and linguistically responsive; (j) Contact information for resources that the youth/young adult and their family may use before or during a crisis event, including IIBHT 24/7/365 crisis supports; (k) Be provided to the youth/young adult and their family in a format and languages chosen by the youth/young adult and their family no more than 10 days from start of services; (l) The IIBHT team members working with the family must have access to the most up to date version of the Crisis and Safety Plan. (6) The IIBHT provider shall administer an OHA approved outcome measures tool for each youth/young adult: (a) Within 30 calendar days of entry to IIBHT services; (b) Within 30 calendar days prior to discharge from IIBHT services; and (c) Results from the Authority approved outcome measurement tool shall be entered into the Authority-approved data system within 30 days of entry. (8) A referral to Fidelity Wraparound shall be offered to eligible youth/young adults enrolled in IIBHT services at the time of entry and throughout enrollment in services as applicable. (9) A Service Plan shall be completed in accordance with OAR 309-019-0140, in collaboration with the youth/young adult and their family and additionally: (a) A LMP shall approve the Service Plan at least annually for everyone receiving mental health services for one or more continuous years. The LMP may designate annual clinical oversight by documenting the designation to a specific licensed health care professional, per service record. (b) The IIBHT Service Plan at a minimum shall include treatment objectives that are agreed to by the youth/young adult or family through signed, informed consent; and (c) Documentation that a minimum of two hours a week, of specific type of IIBHT services have been recommended and documented within the Service Plan, as agreed by the child and family. (d) Locations and time preferences for service delivery, convenient to the youth/young adult and their family. Telehealth may be utilized when requested by the youth/young adult and their family but shall not be the primary mode of service delivery. (e) Projected timeline of IIBHT services and supports for a successful transfer from IIBHT to a lower level of care (f) Name and contact information for all external service providers outside of IIBHT that the family chooses to maintain while enrolled in IIBHT. Provider must document all care coordination efforts in the youth/young adults service record. (g) A copy of the Service Plan must be provided to the youth/young adult and their family in the most developmentally and culturally appropriate language. Statutory/Other Authority: ORS 413.042, 430.640 & 430.705 Statutes/Other Implemented: ORS 430.010, 430.205 & 430.708 History: BHS 3-2025, adopt filed 02/27/2025, effective 03/01/2025 309-021-0170 Treatment Review Meetings (1) IIBHT Treatment Review meetings shall meet the following requirements: (a) Treatment Review meetings shall include, at minimum: (A) The youth/young adult (when clinically appropriate) and their family; (B) Natural supports as approved by the youth/young adult and their family; (C) The youth/young adult’s assigned IIBHT QMHP; and (D) Any other internal or external providers working with the youth/young adult and their family, including mobile crisis representatives if offered by an external organization, or that are chosen by the youth/young adult and their family. (b) An IIBHT treatment review meeting shall be held as often as requested by the youth/young adult and their family, but no less than one time every 90 calendar days. At each meeting, the team shall document the review of: (A) Successes and strengths of the youth/young adult and their family (B) Review of progress towards Service Plan goals, objectives, and interventions; (C) Any updates to the services and supports as determined by the review; (D) Any updates to psychiatric services and recommendations since the last review; (E) Any updates to the Crisis and Safety Plan as determined by the review; (F) Additional interventions to meet the needs of the youth/young adult and their family; (G) Any updates to discharge criteria and transition plan timelines needed for a successful transition from IIBHT services; (H) Youth/young adult and their family’s overall satisfaction with services and supports and any requested changes, updates or adjustment requested. (2) If the youth/young adult is a participant in Fidelity Wraparound, the IIBHT Treatment Review meeting may be included in the regular scheduled Wraparound meeting. The IIBHT provider shall ensure that all IIBHT documentation requirements are met. Statutory/Other Authority: ORS 413.042, 430.640 & 430.705 Statutes/Other Implemented: ORS 430.010, 430.205 & 430.708 History: BHS 3-2025, adopt filed 02/27/2025, effective 03/01/2025 309-021-0180 Proactive Phone Support and In-person Crisis Response (1) IIBHT shall include 24/7/365 support for youth/young adults and their families in the event of a behavioral health crisis. (a) Crisis support shall be available as outlined in the youth/young adult’s individualized Crisis and Safety Plan to provide proactive support and use of skills to deescalate crises (b) Support shall be available by phone at a minimum, and many crises may be managed proactively by phone. When appropriate and requested by the youth/young adult and/or family, support will be offered in person. (2) IIBHT proactive phone support and in-person crisis response shall include the provision and documentation of the following: (a) IIBHT providers shall maintain a policy outlining their procedure that insures youth/young adults and their families enrolled in IIBHT are able to access 24/7/365 proactive phone support and in-person crisis response. (b) IIBHT providers that are unable to provide 24/7/365 in person crisis response shall establish a Memo of Understanding (MOU) with their local Mobile Crisis Intervention team to provide crisis response to IIBHT-enrolled youth/young adults and their families between the hours of midnight and 7am. (c) IIBHT providers must ensure that any staff covering the proactive phone support and/or in-person crisis response for IIBHT meets the following requirements: (A) Staff must be trained in crisis intervention, suicide screening and de-escalation; and (B) Staff must have access to a QMHP who can provide clinical support and consultation; and (C) Staff must have access to the youth/young adult’s most up to date crisis and safety plan (d) All crisis responses must be clearly documented in the youth/young adult’s service record. Documentation must include the following: (A) A description of the incident; (B) A description of the interventions used; (C) A summary of the debrief with the child and family; and (D) Any recommendations for updates to the Crisis and Safety Plan and/or the Service Plan, and a timeframe for the next team meeting. Statutory/Other Authority: ORS 413.042, 430.640 & 430.705 Statutes/Other Implemented: ORS 430.010, 430.205 & 430.708 History: BHS 3-2025, adopt filed 02/27/2025, effective 03/01/2025 309-021-0190 Transition of Care and Transfer Summary (1) IIBHT is a time limited intervention. Youth/young adults and their families may transition to other services when one of the following situations is present: (a) The youth/young person and their family have successfully reached their established goals and objectives in the Service Plan; or (b) The youth/young person and their family requests a transition to a lower level of care; or (c) The youth/young person transitions to a higher level of care, such as residential treatment; or (d) The youth/young person and their family choose to end treatment or move out of the area (2) IIBHT services may overlap with, but shall not duplicate other services, for continuity of care in the following circumstances: (a) prior to the youth/young adult’s discharge from a higher level of care including residential treatment or inpatient hospitalization; or (b) When a youth/young person is temporarily placed in juvenile detention; or (c) When admitted to a brief inpatient psychiatric hospitalization, subacute, or psychiatric residential treatment stay. (3) At the time of transition from IIBHT, the QMHP will complete the IIBHT Transfer Summary in collaboration with the youth/young person and their family, and at a minimum shall document the following: (a) Final Treatment Review Meeting that includes at a minimum the youth/young person, their family, IIBHT QMHP and their next provider (whenever possible); (b) The date and reason for transition; (c) Successes and strengths of youth/young adult and their family; (d) Review of progress made toward goals and objectives in Service Plan; (e) Review of the current Crisis and Safety Plan; (f) Recommendations for the next level of care, goals, and objectives for ongoing treatment; (g) A brief summary of the frequency and types of services the youth/young person and their family received while enrolled in IIBHT; (h) Any established appointments, including dates, times, and contact information for providers taking over ongoing treatment, when applicable. (4) The IIBHT provider shall administer an OHA-approved outcome measures tool: (a) At the final Treatment Review meeting or any time within 30 calendar days prior to discharge from IIBHT services; and (b) Results from the OHA-approved outcome measurement tool shall be entered into the OHA-approved data system within 30 days of entry. (5) The IIBHT Provider shall provide a copy of the Transfer Summary and the Crisis and Safety Plan to: (a) The youth/young adult and their family, in the most developmentally and culturally appropriate language, prior to the end of services but not more than 14 business days when translation services are required. (b) The next service provider, no later than seven calendar days following the last day of IIBHT services. (c) IIBHT provider shall document in the youth’s service record that these documents were provided and clearly document reasons if they were not. (6) If the IIBHT provider is unable to contact the youth/young person and their family after multiple attempts during at least a two week time period and it is determined that the youth/young person will be disenrolled from IIBHT services without a final Treatment Review meeting and transition planning, the IIBHT provider must document attempts to contact the youth/young person and their family and send a copy of the Transfer Summary and Crisis and Safety Plan to the youth/young person and their family, no later than seven calendar days of closure. Statutory/Other Authority: ORS 413.042, 430.640 & 430.705 Statutes/Other Implemented: ORS 430.010, 430.205 & 430.708 History: BHS 3-2025, adopt filed 02/27/2025, effective 03/01/2025