Ala. Admin. Code r. 580-2-20-.11

Mental Illness Outreach Services

This regulation establishes program description and operational requirements for mental illness outreach services provided by Alabama Department of Mental Health-licensed agencies, covering three distinct programs: Adult Case Management (needs assessment, care planning, service linkage, and monitoring for adults with serious mental illness), Adult In-Home Intervention (intensive home-based treatment teams for adults with SMI at risk of higher-level placement), and Assertive Community Treatment (multidisciplinary community-based teams providing comprehensive treatment, rehabilitation, and support for adults with SMI and severe functional disability). Operators must document program descriptions, staffing qualifications, admission and discharge criteria, service delivery requirements, and communication access accommodations for recipients who are deaf or have limited English proficiency.

Ala. Admin. Code r. 580-2-20-.11 - Mental Illness Outreach Services 

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The agency shall have a separate program description for each
 Outreach Service/program. The program description shall include all
 requirements per
 
580-2-20-.09
(2)
 
 (a-e) General Clinical Practice and the program(s) criteria as follows:

(1)

Adult Case
 Management.

(a)
 A
 description of the target population of erious mental illness (SMI).

(b)
 Age range.

(c)
 Nature and scope of the program, as
 indicated by the individual recipient needs and preferences.

(d)
 Location of the geographic services area
 for the program.

(e)
 Specifies that
 the program is staffed by qualified individuals whose primary job function is
 case management.

(f)
 Admission
 criteria.

(g)
 Discharge/transfer
 criteria/procedures.

(h)
 The
 following services shall be delivered within the program: 
 
1.
 Recipient Needs Assessment - A Case
 Management provider performs a written comprehensive assessment of the
 recipient's assets, deficits, and needs. The completed assessment shall be
 maintained in the recipient's file. The case management provider gathers the
 following information: 
(i)
 Identifying
 information.

(ii)
 Socialization and
 recreational needs.

(iii)
 Training
 needs for community living.

(iv)

 Vocational needs.

(v)
 Physical
 needs.

(vi)
 Medical care
 concerns.

(vii)
 Social and
 emotional status.

(viii)
 Housing
 and physical environment.

(ix)

 Resource analysis and planning.

2.
 Case Planning - The development of a
 systematic, recipient-coordinated Plan of Care (POC) that: 
 
(i)
 Lists the recipient's needs, strengths,
 and goals.

(ii)
 Lists the actions
 required to meet the identified needs of the recipient.

(iii)
 Is based on the needs assessment and is
 developed through a collaborative process involving the recipient, their family
 or other support system and the case manager.

(iv)
 Is completed in conjunction with the
 needs assessment within the first thirty (30) days of contact with the
 recipient and every six (6) months thereafter as long as the recipient is
 receiving case management services.

(v)
 Is approved by the supervisor.

3.
 Service arrangement - Through
 linkage and advocacy, the case manager coordinates contacts between the
 recipient and the appropriate person or agency. These contacts may be
 face-to-face, phone calls, or electronic communication.

4.
 Social Support - Through interviews with
 the recipient and significant others, the case manager determines whether the
 recipient possesses an adequate personal support system. If this personal
 support system is inadequate or nonexistent, the case manager assists the
 recipient in expanding or establishing such a network through advocacy and
 linking the recipient with appropriate persons, support groups, or
 agencies.

5.
 Reassessment and
 Follow-up - Through interviews and observations, the case manager evaluates the
 recipient's progress toward accomplishing the goals listed in the case plan at
 intervals of six (6) months or less. In addition, the case manager contacts
 persons or agencies providing services to the recipient and reviews the results
 of these contacts, together with the changes in the recipient's needs shown in
 the reassessments and revises the case plan if necessary.

6.
 Monitoring - The case manager determines
 what services have been delivered and whether they adequately meet the needs of
 the recipient. The POC may require adjustments as a result of
 monitoring.

(i)
 Adult
 Case Management Services must be provided by a staff member with a bachelor's
 degree and who has completed a DMH approved Case Manager Training Program. Case
 managers who work with consumers who are deaf must complete training focusing
 on deafness and mental illness by DMH Office of Deaf Services.

(j)
 Adult Case Management Services for
 consumers who are deaf or who have limited English proficiency must be provided
 in a linguistically appropriate manner by staff proficient in the consumer's
 preferred language, or through the use of a qualified interpreter. Proficient
 in American Sign Language is defined as having at least an Intermediate Plus
 level on the Sign Language Proficiency Interview.

(k)
 Adult Case Management Services are
 supervised by either a staff member who has a master's degree and who has
 successfully completed an ADMH approved case management supervisor training
 program, or bachelor's degree with three (3) years mental health case
 management experience who has successfully completed an ADMH approved case
 management training program.

(l)

 Case Managers must possess a valid current driver's license.

(m)
 Most Case Management Services and
 activities will occur on an outreach basis.

(n)
 The following documentation and/or forms
 are required and must be readily identifiable in the recipient's record: 
 
1.
 Completed Needs Assessment using an ADMH
 approved assessment tool.

2.
 Plan
 of Care.

3.
 Progress/Service Notes
 - Notation by Case Manager of date, service duration, nature of service, and
 Case Manager's signature for each contact with the recipient or
 collateral.

4.
 Documentation that
 communication access has been provided for recipients who are deaf or who have
 limited English proficiency.

5.
 The
 use of family members to interpret is discouraged due to the possibility of
 conflicts of interest. If family members are used to interpret, this shall be
 noted on the waiver. Family members under the age of eighteen (18) cannot be
 used as interpreters.

6.

 Programming will be modified to provide effective participation for all
 recipients who are deaf.

(o)
 Authorization and consent forms as
 necessary to carry out case plans.

(2)

Adult In-Home
 Intervention (IHI).

(a)
 A
 description of the target population of serious mental illness (SMI).

(b)
 Age range.

(c)
 Nature and scope of the Program, as
 indicated by individual recipient needs and preferences.

(d)
 A Location of the geographic service area
 for the program.

(e)
 Specifies that
 the program is staffed by qualified individuals whose primary job function is
 Adult IHI.

(f)
 Admission criteria
 that includes at least the following:
1.
 Must
 meet criteria for Serious Mental Illness.

2.
 Must be eighteen (18) years of age or
 older and not otherwise meet the criteria for Transitional Age
 services.

3.
 Clearly documented
 need for more intensive outpatient supports due to at least one (1) of the
 following:
(i)
 An increase in
 symptoms.

(ii)
 Transition from a
 more intensive level of service.

(iii)
 The need to defuse an immediate crisis
 situation.

(iv)
 The need to
 stabilize the living arrangement.

(v)
 The need to prevent out of home
 placement.

(vi)
 A history of
 failure to engage in other outpatient services.

(g)
 Discharge. Policies and procedures shall
 be developed and implemented for discharge from the program under any one or
 more of the following criteria:
1.
 The maximum
 benefits of the intensive in-home service have been reached.

2.
 The treatment plan goals have been met to
 the extent that the in-home therapy services are no longer needed.

3.
 The recipient/family has not responded to
 repeated, documented follow-up by the IHI team during a fourteen (14) day
 period.

4.
 The IHI team is unable
 to meet obvious, suspected or expressed needs of the child recipient and/or
 their family system.

5.
 The
 recipient becomes otherwise unavailable for services during a fourteen (14) day
 period.

(h)
 Transfer or
 referral to a different program outside of IHI will occur when it is determined
 that the transfer will better meet the needs of the recipient. Transfer shall
 be considered under the following conditions: 
 
1.
 The recipient is in need of more intensive
 services than the IHI team can provide.

2.
 The recipient is determined to be in need
 of less intensive services than those provided by the IHI team.

(i)
 Reflects the following
 characteristics and philosophy of Adult In-Home Intervention: 
 
1.
 Home-based treatment is provided by a two
 (2) person treatment team. Duration of treatment is determined on an individual
 basis as indicated on the treatment plan.

2.
 The team is the primary provider of
 services and is responsible for helping recipients in all aspects of community
 living.

3.
 The majority of services
 occur in the community and/ or in places where recipients spend their
 time.

4.
 Services are highly
 individualized both among individual recipients and across time for each
 recipient.

5.
 Persistent, creative
 adaptation of services to be acceptable to recipients provided in a manner of
 unconditional support.

(j)
 There must be an assigned team that is
 identifiable by job title, job description, and job function. IHI shall be
 provided by a two (2) member treatment team that is composed of one of the
 following options:
1.
 Rehabilitation
 Professional Option- One (1) professional with a master's degree in a mental
 health related field and one (1) professional with a bachelor's degree in a
 human services field or one (1) Certified Mental Health Peer Specialist -
 Adult; or

2.
 Registered Nurse
 Option- One (1) registered nurse under Alabama Law and one (1) professional
 with a bachelor's degree in a human services field. or Certified Mental Health
 Peer Specialist - Adult.

3.
 In each
 staffing composition, both team members must complete case management training.
 For Certified Mental Health Peer Specialist - Adult, they shall be certified by
 ADMH as a Certified Peer Specialist - Adult and maintain ADMH Certified Peer
 Specialist - Adult certification.

(k)
 The following key services must be
 delivered within the program when the team is composed of a master's level
 clinician and a case manager or Certified Mental Health Peer Specialist -
 Adult:
1.
 Individual and Family
 Therapy.

2.
 Crises
 Intervention.

3.
 Mental Health
 Consultation/Care Coordination.

4.

 Basic Living Skills.

5.

 Psychoeducational Services/Family Support.

6.
 Case Management/Care
 Coordination.

7.
 Medication
 Monitoring.

8.
 Peer Services, only
 when team member is a Certified Mental Health Peer Specialist -
 Adult.

(l)
 The following
 key services must be delivered within the program when the team is composed of
 a registered nurse and a case manager or Certified Mental Health Peer
 Specialist - Adult:
1.
 Crisis
 Intervention.

2.
 Mental Health
 Consultation/Care Coordination.

3.

 Basic Living Skills.

4.

 Psychoeducational Services/Family Support.

5.
 Case Management/Care
 Coordination.

6.
 Medication
 Monitoring.

7.
 Medication
 Administration.

8.
 Peer Services,
 only when team member is a Certified Mental Health Peer Specialist -
 Adult.

(m)
 The team must
 function in the following manner:
1.
 Services
 should be provided primarily as a team with the team members working
 individually as dictated by recipient need.

2.
 The hours of delivering the IHI services
 shall be flexible to accommodate the scheduling demands and unique issues of
 the target population (before 8:00 a.m. and after 5:00 p.m. as
 needed).

3.
 Documentation should
 reflect that IHI cases are staffed by the team on a regular basis and that
 joint decisions are made regarding the frequency of recipient contact for team
 and individual staff services.

4.

 The intensive nature of this service should be reflected in the average hours
 of direct service provided per person per week.

5.
 The active caseload for a team shall not
 exceed twenty (20) recipients.

(n)
 Recipients who are deaf or limited
 English proficient shall have effective communication access to these services
 provided by staff proficient in the recipient's preferred language a qualified
 interpreter. Proficient in American Sign Language is defined as having at least
 an Intermediate Plus level on the Sign Language Proficiency
 Interview.

(o)
 Documentation that
 communication access has been provided for recipients who are deaf or who have
 limited English proficiency.

(p)

 The use of family members to interpret is discouraged due to the possibility of
 conflicts of interest. If family members are used to interpret, this shall be
 noted on the waiver. Family members under the age of eighteen (18) cannot be
 used as interpreters.

(q)

 Programming will be modified to provide effective participation for all
 recipients who are deaf.

(3)

Assertive Community
 Treatment (ACT).

(a)
 A
 description of the target population of SMI.

(b)
 Age range.

(c)
 Nature and scope of the program as
 indicated by individual recipient needs and preferences.

(d)
 Location of the geographic service area
 for the program.

(e)
 Specifies that
 the program is staffed by qualified individuals whose primary job function is
 specific to ACT.

(f)
 Admission
 criteria that include at least the following: 
 
1.
 A psychiatric diagnosis.

2.
 Admission approval by a psychiatrist,
 licensed psychologist, or the clinical director.

(g)
 Discharge/transfer criteria and
 procedures.

(h)
 Reflects the
 following characteristics and philosophy of Assertive Community Treatment
 Teams: 
1.
 Multi-disciplinary staff organized
 as a team in which members function interchangeably to provide treatment,
 rehabilitation, and support to persons with serious mental illness and severe
 functional disability.

2.
 The team
 is the primary provider of services and is responsible for helping recipients
 in all aspects of community living.

3.
 The majority of services occur in the
 community in places where recipients spend their time.

4.
 Services are highly individualized both
 among individual recipients and across time for each recipient.

5.
 Persistent, creative adaptation of
 services to be acceptable to recipients provided in a manner of unconditional
 support.

(i)
 The
 following services must be delivered within the program as indicated by
 recipient need:
1.
 Intake.

2.
 Medical assessment and
 treatment.

3.
 Medication
 administration.

4.
 Medication
 monitoring.

5.
 Individual, group
 and/or family therapy.

6.
 Case
 management.

7.
 Crisis
 intervention.

8.
 Mental health
 coordination/consultation.

9.

 Psycho-educational services/Family support and education.

10.
 Basic living skills.

(j)
 There must be an assigned team that is
 identifiable by job title, job description, and job function. The team must
 have: 
1.
 Part-time psychiatric
 coverage.

2.
 Three (3) full-time
 equivalent positions which include at least one (1) full-time master's level
 clinician.

3.
 At least .50 FTE
 registered nurse or licensed practical nurse, and

4.
 A fulltime case manager who has completed
 an approved case management training curriculum.

5.
 The remaining .5 FTE position may be
 filled at the agency's discretion by a master's level clinician, a nurse, a
 case manager, or a Certified Peer Specialist - Adult.

(k)
 The team must function in the following
 manner:
1.
 Each member of the team must be
 known to the recipient.

2.
 Each
 member of the team must individually provide services to each recipient in the
 team's caseload.

3.
 The team will
 conduct staffing of all assigned cases at least twice weekly.

4.
 The caseload cannot exceed a one to twelve
 (1:12) staff to recipient ratio where the part-time psychiatrist is not counted
 as one (1) staff member.

(l)
 The program coordinator must have a
 master's degree in a mental health service-related field and at least one (1)
 year of post-master's direct service experience or be a registered nurse with a
 minimum of one (1) year psychiatric experience.

(m)
 Services must be available and
 accessible, including effective communication access for recipients who are
 deaf, hard of hearing, or limited English proficient, to enrolled recipients
 twenty-four (24) hours per day/seven (7) days per week in a manner and at
 locations that are most conducive to recipients' compliance with treatment and
 supports.

(n)
 It is not necessary
 that a member of the ACT team be on call at all times.

(o)
 The program does not limit length of
 stay.

(p)
 The number of contacts by
 individual team members and totally for the team varies according to individual
 recipient need, but shall be:
1.
 A minimum of
 once per week for recipients in a maintenance phase up to several times per day
 for recipients who require it.

2.

 Done in a manner to assure that all team members provide services to and are
 known to the recipient and are capable of stepping in when needed.

(q)
 Recipients who are deaf or
 limited English proficient shall have effective communication access to these
 services provided by staff proficient in the recipient's preferred language, or
 a qualified interpreter. Proficient in American Sign Language is defined as
 having at least an Intermediate Plus level on the Sign Language Proficiency
 Interview.

(r)
 Documentation that
 communication access has been provided for recipients who are deaf or who have
 limited English proficiency.

(s)

 The use of family members to interpret is discouraged due to the possibility of
 conflicts of interest. If family members are used to interpret, this shall be
 noted on the waiver. Family members under the age of eighteen (18)cannot be
 used as interpreters.

(t)

 Programming will be modified to provide effective participation for all
 recipients who are deaf.

(4)

Program for Assertive
 Community Treatment (PACT).

(a)
 A description of the target population of
 SMI.

(b)
 Age range.

(c)
 Nature and scope of the program, as
 indicated by individual recipient needs and preferences.

(d)
 Location of the geographic service area
 for the program.

(e)
 Specifies that
 the program is staffed by qualified individuals whose primary job function is
 specific to PACT.

(f)
 Admission
 criteria that includes at least the following: 
 
1.
 Recipients with severe and persistent
 mental illnesses that seriously impair their functioning in community living.
 Priority is given to people with schizophrenia, other psychotic disorder, or
 bipolar disorders. At least eighty percent (80%) of recipients have a diagnosis
 of schizophrenia, bipolar or major depression.

2.
 Functional impairments demonstrated by at
 least one (1) of the following conditions: 
 
(i)
 Inability to consistently perform the
 range of daily living tasks required for basic adult functioning in the
 community or persistent or recurrent failure to perform daily living tasks
 except with significant support or assistance from others such as friends,
 family, or relatives.

(ii)

 Inability to be consistently employed at a self-sustaining level or inability
 to consistently carry out the maintenance of living environment.

(iii)
 Inability to maintain a safe living
 situation.

3.
 Recipients
 with one (1) or more of the following which are indicators of continuous
 high-service needs (greater than eight (8) hours per month). 
 
(i)
 Two or more admissions per year to acute
 psychiatric hospitals or psychiatric emergency services.

(ii)
 Intractable, severe major symptoms
 (affective, psychotic, suicidal).

(iii)
 Co-existing substance use disorder of
 significant duration (greater than six (6) months).

(iv)
 High risk of or recent criminal justice
 involvement.

(v)
 Inability to meet
 basic survival needs or residing in substandard housing, homeless, or at
 imminent risk of becoming homeless.

(vi)
 Residing in an inpatient bed or in a
 supervised community residence, but clinically assessed as being able to live
 in a more independent living situation if intensive services are provided or
 requiring residential/inpatient placement if more intensive services are not
 available.

4.
 Admission
 approval by a psychiatrist, CRNP/PA working under the supervision of a
 psychiatrist, licensed psychologist, or the Clinical Director.

(g)
 Discharge/transfer criteria
 and procedures that do not limit the amount of time a recipient is on the team,
 that permit the team to remain the contact point for all recipients as needed,
 and that require discharges to be mutually determined by the recipient and the
 team.

(h)
 The description reflects
 that the Program of Assertive Community Treatment (PACT) operates as follows: 
 
1.
 Assumes responsibility for directly
 providing needed treatment, rehabilitation, and support services to identified
 recipients with sever and persistent mental illnesses.

2.
 Minimally refers recipients to outside
 service providers.

3.
 Provides
 services on a long-term care basis with continuity of caregivers over
 time.

4.
 Delivers seventy-five
 percent (75%) or more of the services outside program offices.

5.
 Emphasizes outreach, relationship
 building, and individualization of services.

(i)
 There must be an identifiable team with
 the following characteristics: 
1.
 Clinical
 staff to recipient ratio of one to ten (1:10), excluding the doctor and
 administrative assistant.

2.

 Minimum team size of ten (10) FTE in urban areas, five to seven (5-7) FTE in
 rural areas.

3.
 A psychiatrist or
 CRNP/PA working under the supervision of a psychiatrist ten (10) hours per week
 per thirty (30) recipients.

4.

 Administrative Assistant of one (1) FTE in urban areas and .5 Full-time
 Equivalents in rural areas.

5.

 Full-time master's level clinician as team leader.

6.
 At least eight (8) mental health
 professionals (MA, MSN, RN) in urban areas, five (5) mental health
 professionals (MA, MSN, RN) in rural areas.

7.
 Substance use disorder specialist of, at
 least, one (1) FTE.

8.
 RN, at least
 three (3) FTE in urban areas and one and a half (1.5) FTE in rural
 areas.

9.
 Vocational specialist of,
 at least, one (1) FTE.

10.
 Peer
 specialist of, at least, one (1) FTE.

11.
 Members that work as a team so that all
 team members know and work with all recipients.

(j)
 Program operates, at least, at eighty
 percent (80%) of full staffing for the past twelve (12) months, or since
 program opening, if not in operation for twelve (12) months.

(k)
 The team leader performs the following
 functions:
1.
 Leads daily organizational team
 meetings.

2.
 Leads treatment
 planning meetings.

3.
 Is available
 to team members for clinical consultation.

4.
 Provides one-to-one (1 to 1)
 supervision.

5.
 Functions as a
 practicing clinician.

(l)
 The psychiatrist or CRNP/PA under the
 supervision of a psychiatrist performs the following functions: 
 
1.
 Conducts psychiatric and health
 assessments.

2.
 Supervises the
 psychiatric treatment of all recipients.

3.
 Provides psychopharmacologic treatment of
 all recipients.

4.
 Supervises the
 medication management system.

5.

 Provides individual supportive therapy.

6.
 Provides crisis intervention
 on-site.

7.
 Provides family
 interventions and psychoeducation.

8.
 Attends daily organizational and treatment
 planning meetings.

9.
 Provides
 clinical supervision.

(m)
 The registered nurses perform the
 following functions: 
1.
 Manage medication
 system, in conjunction with doctors.

2.
 Administer and document medication
 treatment.

3.
 Conduct health
 assessments.

4.
 Coordinate services
 with other health providers.

(n)
 The vocational specialist performs the
 following functions: 
1.
 Acts as the lead
 clinician for vocational assessment and planning.

2.
 Maintains liaison with Vocational
 Rehabilitation and training agencies.

3.
 Provides the full range of vocational
 services (job development, placement, job support, career
 counseling).

(o)
 The
 substance abuse specialist performs the following functions: 
 
1.
 Serves on the individual treatment team of
 recipients with substance use disorder.

2.
 Acts as the lead clinician for assessing,
 planning, and treating substance use disorder.

3.
 Provides supportive and cognitive
 behavioral treatment individually and in groups.

4.
 Uses a stage-wise model that is
 non-confrontational, follows behavioral principles, considers interactions of
 mental illness and substance use disorder, and has gradual expectations of
 abstinence.

(p)
 The team
 provides outreach and continuity of care in the following manner: 
 
1.
 At least seventy-five percent (75%) of all
 contacts occur out of the office.

2.
 Difficult-to-engage recipients are
 retained.

3.
 Difficult-to-engage
 recipients are seen two (2) times per month or more.

4.
 Acutely hospitalized recipients are seen
 two (2) times per week or more.

5.

 Long-term hospitalized recipients are seen each week in the hospital.

6.
 The team plans jointly with inpatient
 staff.

(q)
 The program
 provides the following intensity of services: 
 
1.
 The program size does not exceed one
 hundred twenty (120) recipients in urban areas and eighty (80) in rural
 areas.

2.
 The staff to recipient
 ratio does not exceed one to ten (1:10).

3.
 The recipients are contacted face-to-face
 an average of three (3) times per week.

4.
 Unstable recipients are contacted multiple
 times daily.

(r)
 The
 team operates during the following hours: 
1.

 The staff are on duty seven (7) days per week.

2.
 The program operates twelve (12) hours on
 weekdays.

3.
 The program operates
 eight (8) hours on weekends/ holidays.

4.
 The team members are on-call all other
 hours in the urban model.

5.
 In
 rural areas, team members can coordinate after-hours calls with other
 clinicians.

6.
 A team member must
 brief the on-call staff relative to high-risk recipients.

7.
 A team member must provide face-to-face
 services, if necessary.

(s)
 The team is organized and communicates in
 the following manner:
1.
 Organizational team
 meetings are held daily, Monday through Friday.

2.
 The daily meeting concludes within 45 - 60
 minutes.

3.
 The status of each
 recipient is reviewed via daily log and staff report.

4.
 The team leader facilitates the discussion
 and treatment planning.

5.
 Services
 and contacts are scheduled per treatment plans and triage.

6.
 The shift manager determines the staff
 assignments.

7.
 The shift manager
 prepares the daily staff assignment schedule.

8.
 The shift manager monitors/coordinates
 service provision.

9.
 All staff
 contacts with recipients are logged.

(t)
 The team performs assessment and
 treatment planning in the following manner: 
 
1.
 Baseline and ongoing assessments are
 documented in the following areas: 
(i)

 Psychiatric.

(ii)

 Vocational.

(iii)
 Activities of
 daily living and housing.

(iv)

 Social.

(v)
 Family
 interaction.

(vi)
 Substance
 use.

(vii)
 Health.

2.
 Assessments are performed by
 qualified staff.

3.
 Individual
 treatment teams consist of from three to five (3:5) staff per
 recipient.

4.
 Treatment planning
 meetings are held weekly.

5.

 Treatment planning meetings are led by senior staff.

6.
 Recipients participate in formulating
 goals and service plans.

7.

 Problems, goals, and plans are specific and measurable.

8.
 The treatment plans are transferred to
 recipients' weekly schedules.

9.

 The treatment planning schedule is posted two (2) months in advance.

10.
 The treatment plan is reviewed and
 modified at key events in the course of treatment.

(u)
 Case management services are provided as
 follows:
1.
 A case manager is assigned for
 each recipient.

2.
 Other individual
 treatment team staff back-up the case manager.

3.
 The case manager provides supportive
 services, family support, education and collaboration, and crisis
 intervention.

4.
 The case manager
 plans, coordinates, and monitors services.

5.
 The case manager advocates for the
 recipient and provides social network support.

6.
 All staff perform case management
 functions.

(v)
 Crisis
 assessment and intervention services are provided as follows: 
 
1.
 Crisis services are provided twenty-four
 (24) hours per day.

2.
 A team
 member is available by phone and face-to-face with back-up by team leader and
 psychiatrist in urban areas.

3.

 After-hour services are provided in rural areas either by the team or through
 collaboration with other emergency service providers.

(w)
 Individual supportive therapy is provided
 as follows:
1.
 Ongoing assessment of symptoms
 and treatment response.

2.

 Education about the illness and medication effects.

3.
 Symptom management education.

4.
 Psychological support, problem solving,
 and assistance in adapting to illness.

(x)
 Medication management is provided as
 follows:
1.
 The psychiatrist actively
 supervises/collaborates with the RN's.

2.
 There is frequent assessment of recipient
 response by the psychiatrist.

3.

 All team members monitor medication effects/ response.

4.
 Medication is managed in accordance with
 the policies and procedures.

(y)
 Substance use disorder services are
 provided as follows: 
1.
 The team includes one
 (1) or more designated substance use disorder specialists.

2.
 All team members assess and monitor
 substance use.

3.
 Interventions
 follow an established co-occurring disorders treatment model.

4.
 Individual interventions are
 provided.

5.
 Group interventions
 are provided.

(z)

 Work-related services are provided as follows: 
 
1.
 Services include an assessment of interest
 and abilities and of effect of mental illness on employment.

2.
 All team members provide vocational
 services that are coordinated by the team vocational specialist.

3.
 An ongoing employment rehabilitation plan
 is developed.

4.
 On-the-job
 collaboration with the recipient and supervisor is provided.

5.
 Off-the-job work-related supportive
 services are provided.

(aa)
 Services for activities of daily living
 include the following training: 
1.
 Self-care
 skills.

2.
 Maintenance of living
 environment skills.

3.
 Financial
 management skills.

4.
 Use of
 available transportation.

5.
 Use of
 health and social services.

(bb)
 The team organizes leisure time
 activities. Services for social, interpersonal relationship, and leisure time
 include the following: 
1.
 Communication skill
 training.

2.
 Interpersonal
 relations skill training.

3.
 Social
 skills training.

4.
 Leisure time
 skills training.

5.
 Support to
 recipients in participating in social, recreational, educational, and cultural
 community activities.

(cc)
 Support services are provided and
 include the following:
1.
 Access to medical
 and dental services.

2.
 Assistance
 in finding and maintaining safe, clean affordable housing.

3.
 Financial management support.

4.
 Access to social services.

5.
 Transportation and access to
 transportation.

6.
 Legal
 advocacy.

(dd)

 Recipients who are deaf or have limited English proficiency shall have
 effective communication access to these services provided by staff proficient
 in the recipient's preferred language, or by a qualified interpreter.
 Proficient in American Sign Language is defined as having at least an
 Intermediate Plus level on the Sign Language Proficiency Interview.

(ee)
 Documentation that communication access
 has been provided for recipients who are deaf or who have limited English
 proficiency.

(ff)
 The use of family
 members to interpret is discouraged due to the possibility of conflicts of
 interest. If family members are used to interpret, this shall be noted on the
 waiver. Family members under the age of eighteen (18) cannot be used as
 interpreters.

(gg)
 Programming will
 be modified to provide effective participation for all recipients who are
 deaf.

(5)

Individual Placement and Support - Supported Employment
 (IPS-SEP).

(a)
 A
 description of the target population of serious mental illness (SMI).

(b)
 Age range.

(c)
 Nature and scope of the program, as
 indicated by individual recipient needs and preferences.

(d)
 Location of the geographic service area
 for the program.

(e)
 Specifies that
 the program is staffed by qualified individuals whose primary job function is
 IPS-SEP.

(f)
 Admission criteria
 shall address inclusionary criteria as follows: 
 
1.
 Presence of a psychiatric
 diagnosis.

2.
 Mild to moderate
 persistent, chronic, and/or refractory symptoms and impairments in one (1) or
 more areas of living (e.g., difficulty attaining & sustaining life goals
 and/or community integration).

3.

 Recipient has expressed interest in employment as a recovery goal.

(g)
 IPS-SEP services are
 reasonably expected to improve the individual's functional level, increase
 quality of life, and facilitate attainment of personal life goals to include
 goals for competitive employment or supported education.

(h)
 Once determined to need admission
 criteria, no exclusionary criteria for IPS-SEP shall be implemented. Recipients
 are not screened out formally or informally. All recipients interested in
 working have access to IPS-SEP regardless of job readiness factors, substance
 use disorder, symptoms, history of violent behavior, cognition impairments,
 treatment non-adherence, and personal presentation.

(i)
 Discharge/transfer criteria shall include
 the following:
1.
 Employment or educational
 goals have been met and the individual no longer needs this type of
 service.

2.
 The individual chooses
 to no longer participate.

(j)
 The program does not limit length of
 stay.

(k)
 IPS-SEP constitutes
 services and supports that specifically address the individual's
 employment/educational goals. The IPS-SEP should include an individualized
 employment goal identified on the treatment plan. Based upon the individual's
 needs and preferences, the following services shall be provided at a minimum by
 the IPS-SEP:
1.
 Vocational profile and
 assessment.

2.
 Employment Search
 Plan to include career/education/training. 

3.
 Rapid Job Search/Job
 Development.

4.
 Job coaching/On the
 job supports.

5.
 Follow Along
 Employment/Education Supports.

6.

 Assertive Engagement and Outreach.

7.
 Benefits/Incentives Planning.

8.
 Peer Support.

(l)
 There must be an identifiable team with
 the following staff configuration and credentials: 
 
1.
 The part-time Program Coordinator shall
 serve as the team leader/supervisor. The coordinator shall have a bachelor's
 degree in a human services field or alternatively, two years' experience
 working as an IPS-SEP team member. The supervisor shall complete the ADMH
 approved IPS-SEP Supervisor's training within the first six (6) months of
 hire.

2.
 At minimum, two (2)
 full-time Employment Specialists shall have a high school diploma or equivalent
 with either knowledge of the field of employment or experience in providing
 services to individuals with serious mental illness and/or providing employment
 services to disabled populations. The Employment Specialist shall complete the
 ADMH approved IPS-SEP Practitioner's training within the first six (6) months
 of hire.

3.
 One (1) full-time or
 two (2) part-time MI Adult Peer Specialist(s) who successfully complete peer
 specialist certification through ADMH within first six (6) months of hire and
 possess a high school diploma or equivalent.

4.
 One (1) full-time Benefits Specialist must
 possess either a nationally approved certification recognized by ADMH or will
 have a high school diploma or equivalent and obtain a nationally approved
 certification recognized by ADMH within the first twelve (12) months of
 hire.

(m)
 The team shall
 function and provide activities in the following manner: 
 
1.
 Employment Specialists shall maintain a
 staff to recipient ratio of no greater than one to twenty (1:20).

2.
 Individualized benefits plan before
 starting a job.

3.
 IPS-SEP Team may
 be available after hours on a case- by-case basis as needed for provision of
 services.

(n)
 The Team
 leader (IPS-SEP Supervisor) shall preform the following functions: 
 
1.
 Conduct weekly group supervision with
 IPS-SEP team focusing on recipient goals, employer relationships, and
 celebrations.

2.
 Conduct field
 mentoring activities.

(o)
 Recipients who are deaf or limited
 English proficient shall have effective communication access to these services
 provided by staff proficient in the recipient's preferred language, or a
 qualified interpreter. Proficient in American Sign Language is defined as
 having at least an Intermediate Plus level on the Sign Language Proficiency
 Interview.

(p)
 Documentation that
 communication access has been provided for recipients who are deaf or who have
 limited English proficiency.

(q)

 The use of family members to interpret is discouraged due to the possibility of
 conflicts of interest. If family members are used to interpret, this shall be
 noted on the waiver. Family members under the age of eighteen (18) cannot be
 used as interpreters.

(r)

 Programming will be modified to provide effective participation for all
 recipients who are deaf.

(6)

First Episode Psychosis
 Program (FEP).

(a)
 A
 description of the target population of serious mental illness (SMI)/serious
 emotional disturbance (SED).

(b)

 Age range.

(c)
 Nature and scope of
 the program, as indicated by individual recipient needs and
 preferences.

(d)
 Location of the
 geographic service area for the program.

(e)
 Specifies that the program is staffed by
 qualified individuals whose primary job function is specific to FEP.

(f)
 Admission criteria that include at least
 the following: 
1.
 Presence of a primary
 diagnosis of a psychotic/affective disorder as approved by ADMH.

2.
 Age range from 15-25 years at initiation
 of services.

3.
 Recipient must
 agree to participate in treatment.

4.
 Recipient must require intensive treatment
 not available in a less restrictive program and must be experiencing one (1) or
 more of the following symptoms: 
(i)

 Hallucinations or delusions.

(ii)

 Other psychotic symptoms.

(iii)

 Impaired contact with reality.

(iv)

 Social withdrawal and confusion not warranting hospitalization.

(v)
 Mild to severe symptoms of
 mania.

(vi)
 Mild to severe or
 disabling anxiety.

(vii)

 Inappropriate problem-solving skills.

(viii)
 Inappropriate attention seeking
 behavior.

(ix)
 Poor adherence to
 medication regiment or immediate need for medication.

5.
 Admission is approved by a Licensed
 Independent Practitioner.

(g)
 Exclusionary criteria must be included.
 All recipients receiving treatment from the program will be evaluated at
 admission and periodically after admission to determine if any of the following
 exclusionary criteria are met. If a recipient is found to meet one (1) or more
 of the following criteria, the recipient will be provided with a referral to
 the appropriate treatment setting. Exclusionary criteria include the following:
 
1.
 The needs identified in the referral to
 FEP does not meet admission criteria.

2.
 The needs identified in the referral to
 FEP are not directly related to a primary SMI diagnosis.

3.
 The recipient is placed in a hospital
 and/or Child and Adolescent Psychiatric Residential Treatment Facility (PRTF)
 setting and is not expected to discharge within ninety to one hundred eighty
 (90 to 180) days.

4.
 Recipient has
 a primary diagnosis of substance use disorder.

5.
 Recipient has primary diagnosis of a
 physical illness that requires a more intensive treatment setting which
 precludes participation in treatment in an ambulatory treatment
 setting.

6.
 Recipient has a primary
 diagnosis of an organic or neurological mental disorder that precludes
 participation in treatment in an ambulatory treatment setting.

7.
 Recipient has a primary diagnosis of an
 intellectual/developmental disability, to include autism spectrum disorder
 (ASD).

(h)

 Discharge/transfer criteria and procedures shall be developed. This setting is
 not designed to provide long term outpatient care. Each recipient engaged in
 care through the program will have the next treatment provider identified by
 the end of the second year of treatment. Recipients shall be considered for
 discharge if one (1) or more of the following conditions are met: 
 
1.
 Recipient is found to meet one (1) or more
 of the exclusionary criteria.

2.

 Recipient fails to adhere to the treatment plan established jointly by the
 recipient and treatment team.

3.

 All goals on the treatment plan have been met.

(i)
 First Episode Psychosis Program Reflects
 the following characteristics and philosophy of the: 
 
1.
 Trans-disciplinary staff organized as a
 team in which members function interchangeably to provide treatment,
 rehabilitation and support to recipients experiencing psychosis.

2.
 The team is the primary provider of
 services and is responsible for helping recipients in all aspects of community
 living.

3.
 The majority of services
 occur in the community in places where recipients spend their time.

4.
 Services are highly individualized both
 among individual recipients and across time for each recipient.

5.
 Emphasizes outreach, relationship
 building, and individualization of services.

(j)
 There shall be an identifiable team with
 the following characteristics:
1.
 Clinical
 staff to consumer ratio of one to ten (1:10), excluding the psychiatrist and
 nurse.

2.
 A Master's level clinical
 coordinator of, at least, one (1) FTE who has at least two (2) years of
 treatment experience in a mental health setting.

3.
 A psychiatrist, Physician Assistant (PA)
 or Certified Registered Nurse Practitioner (CRNP) working under the supervision
 of a psychiatrist, of, at least, .33 FTE.

4.
 A licensed practical nurse or registered
 nurse of, at least, .5 FTE

5.
 A
 Care Coordinator of, at least, one (1) FTE who has a minimum of a bachelor's
 level degree and has completed the ADMH approved Child and Adolescent Intensive
 Care Coordination Training.

6.
 A
 Supported Employment/Education Specialist of, at least, one (1) FTE who has a
 minimum of a high school diploma or equivalent and has completed the ADMH
 Individualized Placement Support - Supported Employment (IPS- SEP) and the ADMH
 approved Child and Adolescent Intensive Care Coordination Trainings.

7.
 A Certified Peer Specialist-Youth of, at
 least, .5 FTE who has completed the ADMH approved Certified Peer Specialist -
 Youth Training.

8.
 A Certified Peer
 Specialist-Parent of, at least, .5 FTE who has completed the ADMH approved
 Certified Peer Specialist - Parent Training.

9.
 Each team member is responsible for
 performing all the specific duties and responsibilities identified for their
 position as outlined in the FEP Model. The team members will adhere to the
 fidelity of the identified model.

10.
 Members work as a team so that the entire
 team knows and works with all recipients.

11.
 FEP services are supervised by a staff
 member who has a master's degree and two (2) years of post-master's clinical
 experience and who has completed an ADMH approved Intensive Care Coordination
 Training. The record shall document a minimum of one (1) hour of face-to-face
 staffing consultation with the supervisor weekly as documented in clinical
 chart and shall include any recommendations made to the team.

(k)
 The following services must be
 delivered within the program as appropriate for the recipient: 
 
1.
 Intake Evaluation.

2.
 A systematic determination of the specific
 human service needs of each recipient and their family (if appropriate) as well
 as a clinical assessment that demonstrates the need for this level of service.
 The needs determination shall be based upon the approved ADMH functional
 assessment tool.

3.
 Person Centered
 Treatment Planning with the development of a written plan that is completed by
 the fifth face-to-face or by the thirtieth (30
th
)
 day of enrollment.

4.
 Individual
 Therapy/Counseling.

5.
 Family
 Therapy/Counseling.

6.
 Group
 Therapy/Counseling.

7.

 Psychoeducational Services (Family Support).

8.
 Physician Assessment and
 Treatment.

9.
 Medication
 Administration.

10.
 Medication
 Monitoring.

11.
 Crisis Intervention
 and Resolution.

12.

 Pre-Hospitalization Screening.

13.

 Mental Health Care Coordination/Case Consultation.

14.
 Intensive Care Coordination/Case
 Management.

15.
 Community
 Integration Support Services.

16.

 Education/Employment Support Services.

17.
 Youth Peer Support Services.

18.
 Family Peer Support Services.

19.
 Basic Living Skills.

20.
 Community Outreach to educate the
 community regarding services and the referral process.

21.
 Treatment Plan Review.

(l)
 The Team shall function in the
 following manner:
1.
 The team will convene a
 staffing of active recipients at a minimum of one (1) time per week.

2.
 The hours of delivering the FEP services
 shall be flexible to accommodate the scheduling demands and unique issues of
 the target population (before 8:00 a.m. and after 5:00 pm as needed).

(m)
 The anticipated length of stay
 for the FEP program is two (2) years.
1.
 The
 FEP team has the option of extending services for an additional one (1) year if
 treatment needs are clearly indicated, with prior approval from ADMH.

(n)
 Upon discharge from the FEP
 program, the team will link the recipient and family to follow up services as
 appropriate.

(o)
 Recipients who are
 deaf or limited English proficient shall have effective communication access to
 these services provided by staff proficient in the recipient's preferred
 language, or a qualified interpreter. Proficient in American Sign Language is
 defined as having at least an Intermediate Plus level on the Sign Language
 Proficiency Interview.

(p)

 Documentation that communication access has been provided for recipients who
 are deaf or who have limited English proficiency.

(q)
 The use of family members to interpret is
 discouraged due to the possibility of conflicts of interest. If family members
 are used to interpret, this shall be noted on the waiver. Family members under
 the age of eighteen (18) cannot be used as interpreters.

(r)
 Programming will be modified to provide
 effective participation for all recipients who are deaf

(7)

Child and Adolescent
 Low Intensity Care Coordination (LICC).

(a)
 A description of the target population of
 SED/SMI.

(b)
 Age range.

(c)
 Nature and scope of the program, as
 indicated by individual recipient needs and preferences.

(d)
 Location of the geographic service area
 for the program.

(e)
 Specifies that
 the program is staffed by qualified individuals whose primary job function is
 specific to LICC.

(f)
 Admission
 criteria.

(g)
 Discharge/transfer
 criteria and procedures shall include:
1.
 The
 treatment plan goals have been met to the extent that LICC is no longer needed
 to prevent worsening of the recipient's mental health needs.

2.
 The recipient is placed in a hospital,
 psychiatric residential treatment facility, or other residential treatment
 setting and is not expected to discharge within ninety to hundred-eighty (90 to
 180) days.

3.
 Required consent for
 treatment is withdrawn.

4.
 The
 recipient is not making progress toward treatment goals and there is no
 reasonable expectation of progress at this level of care, and this level of
 care is not required to prevent worsening of the recipient's mental health
 condition.

(h)

 Exclusionary Criteria includes any of the following: 
 
1.
 The needs identified in the referral to
 LICC do not meet admission criteria.

2.
 The needs identified in the referral to
 LICC are not directly related to a primary SED or SMI diagnosis. Individuals
 with the following conditions are excluded from admission unless there is a
 psychiatric condition co-occurring with one (1) of the following diagnoses: 
 
(i)
 Substance Use Disorder.

(ii)
 Developmental Disability.

(iii)
 Autism.

(iv)
 Organic Mental Disorder.

(v)
 Traumatic Brain Injury.

3.
 The person(s) with authority to
 consent to medical treatment for the youth does not voluntarily consent to
 participate in LICC.

4.
 The
 recipient is placed in a hospital, psychiatric residential treatment facility,
 or other residential treatment setting and is not expected to discharge within
 ninety to one hundred-eighty (90 to 180) days.

(i)
 The following services shall be delivered
 within the program:
1.
 Recipient Needs
 Assessment - A LICC provider performs a written comprehensive assessment of the
 recipient's assets, deficits, and needs. The completed assessment shall be
 maintained in the recipient's file. The LICC provider gathers the following
 information:
(i)
 Identifying
 information.

(ii)
 Socialization and
 recreational needs.

(iii)
 Training
 needs for community living.

(iv)

 Vocational needs.

(v)
 Physical
 needs.

(vi)
 Medical care
 concerns.

(vii)
 Social and
 emotional status.

(viii)
 Housing
 and physical environment.

(ix)

 Resource analysis and planning.

(x)

 The needs assessment must be completed or reviewed within fourteen (14) days of
 the first face-to-face care coordination contact and reviewed/updated every six
 (6) months or less thereafter as long as the recipient is receiving services
 (LICC).

2.
 Case Planning
 - The development of a systematic, recipient-coordinated Plan of Care (POC)
 that: 
(i)
 Lists the recipient's needs,
 strengths, and goals.

(ii)
 Lists
 the actions required to meet the identified needs of the recipient.

(iii)
 Is based on the needs assessment and is
 developed through a collaborative process involving the recipient, their family
 or other support system and the care coordinator.

(iv)
 Is completed in conjunction with the
 needs assessment within the first thirty (30) days of contact with the
 recipient and every six (6) months thereafter as long as the recipient is
 receiving LICC services.

(v)
 Is
 approved by the supervisor.

3.
 Service arrangement - Through linkage and
 advocacy, the care coordinator coordinates contacts between the recipient and
 the appropriate person or agency. These contacts may be face-to-face, phone
 calls, or electronic communication.

4.
 Social Support - Through interviews with
 the recipient and significant others, the care coordinator determines whether
 the recipient possesses an adequate personal support system. If this personal
 support system is inadequate or nonexistent, the care coordinator assists the
 recipient in expanding or establishing such a network through advocacy and
 linking the recipient with appropriate persons, support groups, or
 agencies.

5.
 Reassessment and
 Follow-up - Through interviews and observations, the care coordinator evaluates
 the recipient's progress toward accomplishing the goals listed in the case plan
 at intervals of six months or less. In addition, the care coordinator contacts
 persons or agencies providing services to the recipient and reviews the results
 of these contacts, together with the changes in the recipient's needs shown in
 the reassessments and revises the case plan if necessary.

6.
 Monitoring - The care coordinator
 determines what services have been delivered and whether they adequately meet
 the needs of the recipient. The POC may require adjustments as a result of
 monitoring.

(j)
 LICC
 Services shall be provided by a staff member with a bachelor's degree and who
 has completed a Child and Adolescent ADMH approved Case Management Training
 Program. Care coordinators who work with recipients who are deaf must complete
 training focusing on deafness and mental illness by ADMH Office of Deaf
 Services.

(k)
 LICC Services for
 recipients who are deaf or limited English proficient shall have effective
 communication access to these services provided by: 
 
1.
 Staff fluent in the recipient's preferred
 language, or

2.
 A qualified
 interpreter.

3.
 Staff working with
 recipients who are deaf shall have at least an Intermediate Plus level on the
 Sign Language Proficiency Interview.

4.
 Programming will be modified to provide
 effective participation for all recipients who are deaf.

(l)
 Child and Adolescent LICC Services are
 supervised by either a staff member who has a master's degree who has
 successfully completed an ADMH approved child and adolescent LICC training
 program or bachelor's degree with three (3) years child and adolescent mental
 health Case Management/care coordination experience who has successfully
 completed an ADMH approved child and adolescent case management/care
 coordination training program.

(m)

 Care coordinators must possess a current valid driver's license.

(n)
 Most LICC services and activities will
 occur on an outreach basis.

(o)
 The
 following documentation and/or forms are required and must be readily
 identifiable in the recipient's record or on the ADMH website (for needs
 assessment): 
1.
 Completed or reviewed Needs
 Assessment using an ADMH approved assessment tool.

2.
 Plan of Care

3.
 Progress/Service Notes - Notation by care
 coordinator of date, service duration, nature of service, and care
 coordinator's signature for each contact with the recipient or
 collateral.

4.
 Documentation that
 communication access has been provided for recipients who are deaf or who have
 limited English proficiency.

(p)
 Services for recipients who are deaf or
 who have limited English proficiency must be provided in a linguistically
 appropriate manner by staff proficient in the recipient's preferred language,
 or through the use of a qualified interpreter Proficient in American Sign
 Language is defined as having at least an Intermediate Plus level on the Sign
 Language Proficiency Interview.

(q)

 The use of family members to interpret is discouraged due to the possibility of
 conflicts of interest. If family members are used to interpret, this shall be
 noted on the waiver. Family members under the age of eighteen (18) cannot be
 used as interpreters.

(r)

 Programming will be modified to provide effective participation for all
 recipients who are deaf.

(s)

 Authorization and consent forms as necessary to carry out care plans.

(8)

Child and Adolescent High Intensity Care Coordination
 (HICC).

(a)
 A description
 of the target population of serious emotional disturbance (SED) and/or a
 serious mental illness (SMI).

(b)

 Age range.

(c)
 Nature and scope of
 the program, as indicated by individual recipient needs and
 preferences.

(d)
 Location of the
 geographic service area for the program.

(e)
 Specifies that the program is staffed by
 qualified individuals whose primary job function is specific to HICC.

(f)
 Admission criteria includes presence of a
 SED and/or a SMI; and at least one (1) of the following: 
 
1.
 The recipient is involved in multiple
 child-serving systems or is at risk.

2.
 The recipient has more intensive needs
 (such as admissions to inpatient psychiatric hospitals and/or residential) or
 is at risk.

3.
 The recipient's
 treatment requires cross-agency collaboration.

(g)
 Discharge/transfer criteria/procedures.
 Discharge criteria includes the following: 
1.

 The treatment plan goals have been met to the extent that HICC is no longer
 needed to prevent worsening of the recipient's mental health needs.

2.
 The recipient is not engaged in treatment
 during a ninety (90) day period despite multiple, documented attempts to
 address engagement or lack thereof.

3.
 The recipient is placed in a hospital,
 psychiatric residential treatment facility, or other residential treatment
 setting and is not expected to discharge within ninety to hundred-eighty (90 to
 180) days.

4.
 Required consent for
 treatment is withdrawn.

5.
 The
 recipient is not making progress toward treatment goals and there is no
 reasonable expectation of progress at this level of care, and this level of
 care is not required to prevent worsening of the recipient's mental health
 condition.

6.
 Exclusionary Criteria
 includes any of the following:
(i)
 The needs
 identified in the referral to HICC do not meet admission criteria.

(ii)
 The needs identified in the referral to
 HICC are not directly related to a primary SED or SMI diagnosis. Individuals
 with the following conditions are excluded from admission unless there is a
 psychiatric condition co-occurring with one (1) of the following diagnoses: 
 
(I)
 Substance Use Disorder.

(II)
 Developmental Disability.

(III)
 Autism.

(IV)
 Organic Mental Disorder.

(V)
 Traumatic Brain Injury.

(iii)
 The person(s) with authority
 to consent to medical treatment for the youth does not voluntarily consent to
 participate in HICC.

(iv)
 The
 recipient is placed in a hospital, psychiatric residential treatment facility,
 or other residential treatment setting and is not expected to discharge within
 ninety to one hundred-eighty (90 to 180) days.

7.
 Continued stay criteria includes the
 following:
(i)
 The recipient is continuing to
 make progress toward treatment goals and there is a reasonable expectation of
 progress at this level of care; or

(ii)
 This level of care is required to
 prevent worsening of the recipient's mental health condition.

(h)
 The following
 services must be delivered within the program: 
 
1.
 The first face-to-face appointment within
 seven (7) days of the recipient's acceptance of HICC.

2.
 The ADMH approved Functional Assessment
 must be completed or reviewed with the recipient within fourteen (14) days of
 the first face-to-face care coordination contact and reviewed/updated with the
 recipient every six (6) months or less thereafter as long as the recipient is
 receiving HICC services.

3.
 The
 ADMH approved Crisis Stabilization and Support Plan must be completed or
 reviewed with the recipient within fourteen (14) days of the first face-to-face
 care coordination contact and reviewed and updated regularly, but at a minimum
 of every six (6) months.

4.
 The
 development of a systematic, recipient-coordinated Plan of Care (POC) must be
 completed within thirty (30) days of the first face-to-face care coordination
 contact with the recipient and every six months thereafter as long as the
 recipient is receiving HICC services. The HICC is required to convene the child
 and family team (CFT) to complete the POC. All POCs must be approved by the
 supervisor.

5.
 Service arrangement
 - Through linkage and advocacy, the HICC coordinates contacts between the
 recipient and the appropriate person or agency. These contacts may be
 face-to-face, phone calls, or electronic communication.

6.
 Social Support - Through interviews with
 the recipient and significant others, the HICC determines whether the recipient
 possesses an adequate personal support system. If this personal support system
 is inadequate or nonexistent, the HICC assists the recipient in expanding or
 establishing such a network through advocacy and linking the recipient with
 appropriate persons, support groups, or agencies.

7.
 Reassessment and Follow-up - Through
 interviews and observations, the HICC evaluates the recipient's progress toward
 accomplishing the goals listed in the POC at intervals of six (6) months or
 less. In addition, the HICC contacts persons or agencies providing services to
 the recipient and reviews the results of these contacts, together with the
 changes in the recipient's needs shown in the reassessments and revises the POC
 if necessary.

8.
 Monitoring - The
 HICC determines what services have been delivered and whether they adequately
 meet the needs of the recipient. The POC may require adjustments as a result of
 monitoring.

(i)
 HICC
 Services must be provided by a staff member with a bachelor's degree in a human
 service-related field or a registered nurse. Both shall complete an ADMH
 approved Child and Adolescent Intensive Care Coordination Training Program
 within an ADMH approved timeline.

(j)
 HICC who work with recipients who are
 deaf must complete training focusing on deafness and mental illness by ADMH
 Office of Deaf Services.

(k)
 Child
 and Adolescent HICC Services are supervised by either a staff member who has a
 master's degree who has successfully completed an ADMH approved Child and
 Adolescent Intensive Care Coordination Training Program or bachelor's degree in
 a human service field with three (3) years child and adolescent mental health
 case management/care coordination experience who has successfully completed an
 ADMH Child and Adolescent Intensive Care Coordination Training
 Program.

(l)
 The active caseload
 for a HICC shall not exceed eighteen (18) Recipients.

(m)
 HICCs must possess a current valid
 driver's License.

(n)
 Most HICC
 Services and activities will occur on an outreach basis.

(o)
 The following documentation and/or forms
 are required and must be readily identifiable in the recipient's record or on
 the ADMH website:
1.
 Completed or reviewed
 Functional Assessment using ADMH approved assessment tool.

2.
 Plan of Care - Goals, methods of
 accomplishment, and approval of same by HICC supervisor.

3.
 Service Notes - Notation by HICC of date,
 service duration, nature of service, and HICC's signature for each contact with
 the recipient or collateral.

4.

 Documentation that communication access has been provided for recipients who
 are deaf or who have limited English proficiency.

5.
 The use of family members to interpret is
 discouraged due to the possibility of conflicts of interest. If family members
 are used to interpret, this shall be noted on the waiver. Family members under
 the age of eighteen (18) cannot be used as interpreters.

(p)
 Services for recipients who are deaf or
 who have limited English proficiency must be provided in a linguistically
 appropriate manner by staff proficient in the recipient's preferred language,
 or through the use of a qualified interpreter Proficient in American Sign
 Language is defined as having at least an Intermediate Plus level on the Sign
 Language Proficiency Interview.

(q)

 Programming will be modified to provide effective participation for all
 recipients who are deaf.

(r)

 Authorization and consent forms as necessary to carry out case
 plans.

(9)

Child
 and Adolescent In-Home Intervention.

(a)
 A description of the target population of
 serious emotional disturbance (SED)/serious mental illness (SMI).

(b)
 Age range.

(c)
 Nature and scope of the program, as
 indicated by individual recipient needs and preferences.

(d)
 Location of the geographic service area
 for the program.

(e)
 Specifies that
 the program is staffed by qualified individuals whose primary job function is
 specific to Child and Adolescent In-Home Intervention.

(f)
 Admission criteria that include at least
 the following:
1.
 Presence of a serious
 emotional disturbance (SED and/or serious mental illness (SMI).

2.
 Age ranges from five to twenty (5-20)
 years (exception of Transitional Age specialized teams which are age range of
 17-25).

3.
 IQ of 70 or above
 (exception of MI/ID specialized teams in which both team members have
 documentation in their personnel file of at least five (5) hours of training
 specific to addressing the ID/DD population within one (1) year from the date
 they began providing services, with two (2) hours annually thereafter. In
 addition, they must complete the required ten (10) hours training within one
 (1) year from the date they began providing such services for the specialty
 population of children and adolescents).

4.
 Clearly documented need to defuse a crisis
 situation, stabilize the family unit, or reduce the likelihood of the need for
 more intensive or restrictive services.

5.
 The recipient resides in a family home
 environment (e.g., foster, adoptive, birth, kinship).

6.
 Admission is approved by a Licensed
 Independent Practitioner.

(g)
 Discharge criteria. Policies and
 procedures shall be developed and implemented for discharge from the program
 under one (1) or more of the following criteria: 
 
1.
 The treatment plan goals have been met to
 the extent that the intensive in-home therapy services are no longer needed to
 prevent worsening of the recipient's mental health needs.

2.
 The recipient is not engaged in treatment
 during a fourteen (14) day period despite multiple documented attempts to
 address engagement or lack thereof.

3.
 The IHI team is unable to meet obvious,
 suspected or expressed needs of the recipient.

4.
 The recipient is placed in a hospital,
 skilled nursing facility, psychiatric residential treatment facility, or other
 residential treatment setting.

5.

 Required consent for treatment is withdrawn.

6.
 The recipient is not making progress
 toward treatment goals and there is no reasonable expectation of progress at
 this level of care, and this level of care is not required to prevent worsening
 of the recipient's mental health condition.

(h)
 Transfer or referral to a different
 program outside of IHI will occur when it is determined that the transfer will
 better meet the needs of the recipient and/or family. Transfer or referral
 shall be considered under the following conditions: 
 
1.
 The recipient is in need of more intensive
 services than the IHI team can provide.

2.
 The recipient is determined to be in need
 of less intensive services than those dictated by the IHI model and therefore
 recipient is no longer in need of more intensive or restrictive
 services.

3.
 The child or
 adolescent recipient and his/her family are receiving duplicate services from
 another child-serving agency that either cannot be terminated or are preferred
 by the family in lieu of IHI services.

(i)
 Exclusionary criteria that include any of
 the following: 
1.
 The needs identified in the
 referral to IHI does not meet admission criteria.

2.
 The needs identified in the referral to
 IHI services are not directly related to a primary SED or SMI diagnosis;
 or

3.
 Individuals with the
 following conditions are excluded from admission unless there is a psychiatric
 condition co-occurring with one (1) of the following diagnoses: 
 
(i)
 Substance Use Disorder.

(ii)
 Developmental Disability.

(iii)
 Autism.

(iv)
 Organic Mental Disorder.

(v)
 Traumatic Brain Injury.

4.
 The recipient is in a hospital,
 skilled nursing facility, psychiatric residential treatment facility or other
 residential treatment setting at the time of referral and is not ready for
 discharge to a family home environment or community setting with
 community-based supports.

5.
 The
 needs identified in the treatment plan that would be addressed by IHI services
 are being fully met by other less restrictive community-based
 services.

6.
 The recipient has
 severe medical conditions or impairments that would prevent any beneficial
 utilization of IHI services.

(j)
 Continued stay criteria include the
 following: 
1.
 The recipient is continuing to
 make progress toward treatment goals and there is a reasonalbe expectation of
 prograss at this level of care; or

2.
 This level of care is required to prevent
 worsening of the recipient's mental health condition.

(k)
 Reflects the following characteristics
 and philosophy of In-Home Intervention: 
1.

 Time-limited, home-based services provided by a two (2) person team consistent
 with wrap-around principles and process. IHI services are limited to twelve
 (12) weeks, subject to two (2) clinical extensions of up to four (4) weeks each
 and additional extensions via the ADMH approved prior authorization
 process.

2.
 The team is the primary
 provider of services and is responsible for helping recipients and/or family in
 of community living.

3.
 The
 majority of services occur in the community in places where recipients spend
 their time.

4.
 If not previously
 assessed with completion of a Psychosocial Assessment/Intake, the IHI team can
 perform the Psychosocial Assessment/Intake as part of the bundled service
 delivery.

(l)
 The
 following services must be delivered within the program: 
 
1.
 A systematic determination of the specific
 human service needs of each recipient and/or family, as well as a comprehensive
 community-based mental health assessment that demonstrates the need for this
 level of service. The needs determination must be based upon the approved the
 ADMH assessment tool(s) and be completed or reviewed with the recipient and/or
 family within the first fourteen (14) days of enrollment.

2.
 The development of an approved ADMH Crisis
 Stabilization and Support Plan (CS&SP) with the youth and/or family, or
 review if already completed, by the fourteenth
 (14
th
) day of the first face-to-face contact. The
 CS&SP shall be developed with input from the youth, family, and support
 individuals identified on the plan.

3.
 The development of a treatment plan based
 on the strengths and needs of the recipient as identified by the ADMH approved
 functional assessment tool, the recipient, and/or the recipient's family shall
 be completed by the thirtieth (30
th)
 day of
 enrollment.

4.
 Individual
 Therapy.

5.
 Family
 Counseling.

6.
 Psychoeducation
 (Family Support and Education).

7.

 Basic Living Skills.

8.
 Crisis
 Intervention twenty-four (24) hour availability.

9.
 Medication Monitoring.

10.
 Mental Health Coordination/Case
 Consultation.

11.
 Treatment Plan
 Review.

(m)
 There must
 be an assigned team that is identifiable by job title, job description, and job
 function. IHI shall be provided by a two (2) member treatment team that is
 composed of the following:
1.
 One (1)
 professional with a master's degree in a mental health-related field or a
 registered nurse licensed under Alabama law, who has completed a master's
 degree in psychiatric nursing; and

2.
 One (1) professional with a bachelor's
 degree in a human services field or a Certified Peer Specialist - Youth
 Parent.

3.
 Both team members must
 have completed an ADMH approved an In-Home Intervention Training program as
 documented in personnel records. In addition, the Certified Peer Specialist -
 Parent must successfully complete an ADMH approved Certified Peer Specialist -
 Parent training as documented in personnel records.

(n)
 The team shall function in the following
 manner:
1.
 The majority of the IHI services
 are to be delivered with the team member together at a frequency of two (2) to
 three (3) direct face-to-face contacts per week during the Assessment Phase;
 two (2) to five (5) direct face-to face contacts per week in the Treatment
 Phase; and one (1) to two (2) direct face-to-face contacts per week during the
 Generalization Phase. 

2.
 The hours
 of delivering the IHI services shall be flexible to accommodate the scheduling
 demands and unique issues of the target population (before 8:00 a.m. and after
 5:00 pm as needed).

3.

 Documentation reflects those services are provided primarily by both team
 members in attendance. If In-Home Intervention services are discontinued,
 enrollees are referred to other services when the team is no longer a two (2)
 person team. Examples would include the loss of one (1) of the team members,
 extended illness, maternity leave, etc. exceeding a two (2) week
 period.

4.
 The active caseload for
 a team shall not exceed six (6) recipients and their families.

5.
 The intensive nature of this service shall
 be reflected in the average hours of direct service provided per family per
 week and documented in the recipient record.

(o)
 IHI services are supervised by a staff
 member who has a master's degree and two (2) years of post-master's clinical
 experience and who has successfully completed an ADMH approved intensive
 In-Home Intervention training program. The record shall document a minimum of
 one (1) hour of face-to-face staffing consultation with the supervisor every
 two (2) weeks as documented in recipient's record and shall include any
 recommendations made to the team.

(p)
 Recipients who are deaf, or limited
 English proficient shall have effective communication access to these services
 provided by staff proficient in the recipient's preferred language, or a
 qualified interpreter. Proficient in American Sign Language is defined as
 having at least an Intermediate Plus level on the Sign Language Proficiency
 Interview.

(q)
 Documentation that
 communication access has been provided for recipients who are deaf or who have
 limited English proficiency.

(r)

 The use of family members to interpret is discouraged due to the possibility of
 conflicts of interest. If family members are used to interpret, this shall be
 noted on the waiver. Family members under the age of eighteen (18) cannot be
 used as interpreters.

(s)

 Programming will be modified to provide effective participation for all
 recipients who are deaf.

(t)
 IHI
 shall reflect the following characteristics and philosophy of Child and
 Adolescent In-Home Intervention:
1.
 IHI
 services and activities shall be provided on an outreach basis. IHI services,
 while by definition and practice are usually provided in the recipient's home,
 infrequently may be provided in other locations such as schools, juvenile
 court, a local park, or clinic, etc.

2.
 The IHI team's priorities shall include: 
 
(i)
 Intervening in a crisis
 situation.

(ii)
 Stabilizing the
 family's ability to effectively manage the child recipient's mental health
 symptoms.

(iii)
 Facilitating the
 reunification of a recipient back into their family upon return from a more
 restrictive treatment placement/facility.

(iv)
 Working with the recipient and/or family
 to implement interventions to advance therapeutic goals or improve ineffective
 patterns of interaction.

(v)

 Coordination with external agencies and stakeholders that may impact the
 recipient's treatment plan.

(vi)

 Referral and linkage to appropriate services along the continuum of
 care.

(vii)
 Coaching in support of
 decision-making in both crisis and non-crisis situations.

(viii)
 Skill development for the recipient
 and/or family.

(ix)
 Monitoring
 progress on attainment of treatment plan goals and objectives.

(u)
 During Assessment
 Phase, week one (1) to four (4) IHI team shall: 
 
1.
 Complete an initial assessment within
 twenty-four (24) hours of the meeting with the youth and/or family to determine
 program eligibility, to include the review of the ADMH approved Referral
 Form.

2.
 Complete or review current
 ADMH approved comprehensive home-based assessment/re-assessment tool(s) by the
 fourteenth (14
th
) day of enrollment.

3.
 Complete or review the Crisis
 Stabilization & Support Plan (CS&SP) by the fourteenth
 (14
th
) day of enrollment.

4.
 Review Intensive Home-Based Services
 (IHBS) and offer appropriate IHBS to the youth and family by the
 30
th
 day of enrollment. When the recipient is not
 actively enrolled in HICC, the offer of services along with the youth and
 family response must be documented on the ADMH approved IHBS Referral Tracking
 Form.

5.
 Collect appropriate
 information from prior and concurrent treatment sources as
 appropriate.

6.
 Assess the
 recipients need to be evaluated by the physician.

7.
 Document assessments and services. If one
 (1) team member is absent, this shall be reflected in the assessment/ progress
 notes.

(v)
 During the
 Treatment Plan Formulation Phase week four (4), the IHI team shall develop the
 treatment plan by the thirtieth (30
th
) day of
 enrollment.

(w)
 During the
 Treatment Phase weeks five (5) to ten (10) IHI team shall address treatment
 plan objectives via a variety of therapeutic approaches, therapeutic
 modalities, and other interventions.

(x)
 During the Generalization Phase weeks ten
 (10) to twelve (12), IHI team shall:
1.

 Continue to follow the IHI model and adjust service delivery when
 indicated.

2.
 Refer the recipient
 and family to appropriate follow-up services, if not already receiving, which
 could include care coordination, Certified Peer Specialist - Youth, Certified
 Peer Specialist - Parent, Therapeutic Mentoring, outpatient therapy, etc. and
 introduce the recipient and family to new service staff.

3.
 Link the recipient and family to the
 outpatient services and conduct transfer session to review progress and any
 future treatment needs/issues for the recipient and their family as
 appropriate.

(y)
 The IHI
 team has the option of extending services beyond the initial twelve (12) weeks
 through two (2) clinical extensions of up to four (4) weeks each if treatment
 needs are clearly indicated, with prior approval of the direct supervisor. A
 Treatment Plan Review/Extension shall be completed documenting the clinical
 reasons for the extension, signed by eligible staff and filed in recipient
 record. Additional extensions beyond twenty (20) weeks require completion of
 the prior authorization process.

Notes

Ala. Admin. Code
 r. 
580-2-20-.11

Adopted by
 
Alabama
 Administrative Monthly Volume XLI, Issue No. 07, April 28, 2023
,
 eff. 
6/12/2023
.

Author:
 Division of Mental Health and Substance
 Use Services, ADMH

Statutory Authority:

Code of Alabama
 1975
, §
 
22-50-11

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