3000, Provision of Mental Illness (MI) Specialized Services

Revision 20-0; Effective August 25, 2020

3100 Refusal of MI Specialized Services

Revision 20-0; Effective August 25, 2020

During the initial Interdisciplinary Team (IDT) meeting, if a person who is Preadmission Screening and Resident Review (PASRR) positive for mental illness (MI)/legally authorized representative (LAR) refuses MI specialized services, the Qualified Mental Health Professional-Community Services (QMHP-CS) must: 

• complete Form 1041, Refusal of PASRR Mental Illness Specialized Services;
• obtain the necessary signatures on Form 1041; 
• provide the person/LAR a copy of the completed Form 1041; 
• maintain a copy of Form 1041 and the PASRR Comprehensive Service Plan (PCSP) form in the person's local mental health authority (LMHA)/local behavioral health authority (LBHA) record; and
• confirm the nursing facility (NF) documented the refusal in Section A3100 of the PCSP.

The LMHA/LBHA must also inform the person/LAR of the need to conduct follow-up visits every 30 days for 90 days after the initial IDT meeting regarding their refusal of specialized services. During these visits, the LMHA/LBHA must attempt to engage them and discuss their need for MI specialized services. These visits must be documented on the PCSP as a Local Authority (LA) update meeting and in the person's LMHA/LBHA record. 

For persons dually diagnosed with MI and intellectual disability (ID)/developmental disability (DD), since the required 90-day follow up is due at the same time as the quarterly Service Planning Team (SPT) meeting, it must be conducted as part of the quarterly SPT meeting. When the local intellectual and developmental disability authority (LIDDA) completes the quarterly meeting on the PCSP, these results will be included as part of their documentation. The refusal of MI specialized services does not impact the need for, and provision of, habilitation coordination or intellectual and developmental disability (IDD) services. However, the person may also refuse all IDD services if they so choose. The LIDDA's habilitation coordinator will follow up with the person for habilitation coordination needs.

Annual IDT Meetings

If the person/LAR continue to refuse MI specialized services during subsequent annual IDT meetings, LMHAs/LBHAs are not required to complete the 30-, 60-, 90-day follow ups nor is a new Form 1041 needed. The NF must continue to document the refusal of MI specialized services in Section A3100 of the PCSP.   

3110 Assignment of Qualified Provider of MI Specialized Services

Revision 20-0; Effective August 25, 2020

An LMHA/LBHA must assign a qualified provider who is at least a QMHP-CS to every person who is PASRR positive for mental illness (MI). The QMHP-CS must complete a face-to-face interview within three days of receiving the alert and complete the PASRR evaluation within seven days of receiving the alert.

The QMHP-CS will ensure there is a current MI diagnosis, a current psychosocial assessment, administer the uniform assessment (UA) and complete a person-centered recovery plan (PCRP) with the person. A diagnostic and psychosocial assessment may be conducted via telemedicine/telehealth, if necessary, when conducted in accordance with 15 Texas Administrative Code (TAC) §354.1432 and 22 TAC §174.9.

3200 Required Uniform Assessment and Person-Centered Recovery Plan

Revision 20-0; Effective August 25, 2020

The MI specialized services provided to a person who is PASRR positive are determined by the LMHA/LBHA staff conducting a uniform assessment (UA), Adult Needs and Strengths Assessment (ANSA) and the person-centered recovery plan (PCRP), which are requirements for admission to a Texas Resilience and Recovery (TRR) Level of Care.

Based on ANSA results, the LMHA/LBHA staff will develop a PCRP with the person and/or their LAR.  

The PCRP will include core services, adjunct services and other supports needed, as determined by the UA. 

In most cases, the clinician who conducts the UA and PCRP will also be the person who provides the specialized services. In the unlikely event the clinician who conducts the UA, the PCRP and provides the specialized services is not the same person, a clinical staffing, which includes the person who is PASRR positive and/or their LAR, must be conducted to make the new clinician fully aware of all pertinent information needed to step into the role of provider of the MI specialized services.

3210 Texas Resiliency and Recovery (TRR) Model

Revision 20-0; Effective August 25, 2020

This philosophy approaches people in need to foster resilience and recovery with respect to MI and severe emotional disturbances. A primary aim of the service delivery system is to ensure the provision of interventions and evidence-based practices with empirical support to promote recovery from psychiatric disorders and resilience from severe emotional disturbances.  

The TRR model, or public mental health service design in Texas, includes the following components:

• Establishes who is eligible to receive services through a uniform assessment Adult Needs and Strengths Assessment (ANSA), which determines a Level of Care Recommended (LOC-R);
• Establishes a plan to manage the use of services, as outlined in the Utilization Management Guidelines, which determines a Level of Care Authorized (LOC-A);
• Measures clinical outcomes or the impact of services; and
• Determines how much these services should cost.

The Utilization Management Guidelines is an integral part of the program to ensure the delivery of mental health services are properly tailored to the person's needs and strengths to achieve the best possible results.

All mental health services must be provided in accordance with 25 TAC, Chapter 412, Subchapter G, MH Community Services Standards: "All staff must demonstrate required competencies before contact with individuals and periodically throughout the staff's tenure of employment or association with the local authority provider system, MCO, or provider."

• Pharmacological Management: Doctor of Medicine (MD), Registered Nurse (RN), Physician Assistant (PA), Doctor of Pharmacy (Pharm D), Advanced Practice Registered Nurse (APRN), Licensed Vocational Nurse (LVN)
• Psychiatric Diagnostic Interview: Licensed Practitioner of Healing Arts (LPHA)
• Counseling: LPHA or LPHA Intern (See Add-On definitions for CPT Provider Requirements)
• Routine Case Management: Qualified Mental Health Professional-Community Services (QMHP-CS) or Community Services Specialist (CSSP)
• Rehabilitative Services: QMHP-CS, Licensed Medical Personnel, CSSP or Peer Provider
• Supported Employment: QMHP-CS or CSSP or Peer Provider
• Supportive Housing: QMHP-CS or CSSP or Peer Provider
• Crisis Intervention Services: QMHP-CS

3220 Adult Needs and Strength Assessment (ANSA) Tool

Revision 20-0; Effective August 25, 2020

ANSA is a multipurpose tool developed for adult behavioral health services. It is intended to:

• Prevent duplicate assessments by multiple parties; 
• Decrease unnecessary psychological testing; 
• Aid in identifying placement and treatment needs; and
• Inform case planning decisions.

Assessments help support decision making, including level of care and service planning, to facilitate quality improvement initiatives, and to allow for outcomes monitoring. The ANSA manual, assessment forms and training information can be reviewed at: https://hhs.texas.gov/doing-business-hhs/provider-portals/behavioral-health-services-providers/comprehensive-providers/adult-needs-strengths-assessment. 

3221 Six Key Principles of the ANSA Tool

Revision 20-0; Effective August 25, 2020

The six key principles of the Adult Needs and Strength Assessment (ANSA) tool are:

1. Items were selected because each one is relevant to service and recovery planning. An item exists because it might lead the clinician down a different pathway in terms of planning actions.
2. Each item uses a four-level rating system. Those levels are designed to translate immediately into action levels. Different action levels exist for needs and strengths.
3. Rating should describe the person, not the individual in services. The assessment should identify what is important to the person, and what is important for the person.
4. The ratings are generally collaborative. This is a descriptive tool including the person's assessed input. It is the "what," not the "why." Only two items, "Adjustment to Trauma" and "Social Behavior," have any cause-effect conclusions.
5. A 30-day window is used for ratings to ensure assessments stay fresh and relevant to the individual present circumstances. However, the action levels can be used to override the 30-day rating period. There is an expectation that success is possible – it's a "chance to get past your past."
6. Consider culture and development before establishing an action level. Cultural sensitivity involves considering whether cultural factors are influencing the expression of needs and strengths. Developmental age is part of cultural consideration.

3222 Reason for ANSA Tool

Revision 20-0; Effective August 25, 2020

The ANSA tool has received positive feedback by recipients, family members, providers and other partners in the services system because it is a collaborative process and doesn't necessarily require scoring to be meaningful to a person and their family. The way ANSA works is that each item suggests different pathways for recovery service provision. There are four levels of each item with anchored definitions; however, these definitions are designed to translate into the following action levels and be scored accordingly (separate for needs and strengths):

For needs

0 = No evidence
1 = Watchful waiting/prevention
2 = Action
3 = Immediate/Intensive Action

For strengths

0 = Centerpiece strength
1 = Strength that you can use in planning
2 = Identified-strength-must be built
3 = No strength identified

3223 Administering the ANSA Tool

Revision 20-0; Effective August 25, 2020

To administer the Texas ANSA tool, the clinician must be, at a minimum, a QMHP-CS. The clinician must have completed the ANSA training and then passed the ANSA certification exam. The certification exam must be renewed annually to retain certification to administer the ANSA tool.  The LMHA/LBHA must conduct at least two annual trainings facilitated by an ANSA "superuser."  The twice annual trainings must be documented. The clinician conducting the ANSA tool must attend at least one of these trainings.

In Texas, the ANSA tool must be updated at least every 180 days. It can be updated at any time and must be updated when there is a change in the person's condition or a change in services.  The ANSA tool should always be current and based on the current condition of the person served.

One of the benefits is the ANSA tool will recommend a level of care (LOC) to which the person can be admitted. The clinician can then make the recommendation to the authority department to authorize the recommended LOC. If the clinician believes a different LOC is more suitable, they can make the case to deviate from the ANSA recommended LOC and ask for a different LOC to be authorized.

Each LOC provides a "package" of services based on the results of the ANSA tool. This means there are specific services designed to meet the needs of the person based on the ANSA's LOC recommendation. This prepares the clinician and the person to move forward with development of the PCRP.

3300 Discovery Process

Revision 20-0; Effective August 25, 2020

Discovery is the process of meeting with the person face to face and listening and learning about what people want from their life. It is getting to know people so that their personal outcomes, preferences, choices and abilities are understood and documented to form the foundation for planning services and supports. 

Discovery is the basis for person-centered planning and service delivery, an ongoing process that occurs each time the LMHA/LBHA provider talks to the person or those who know the person best. 

Recording the information is necessary so it can be used when developing or updating the PCRP. The LMHA/LBHA leads the discovery process, advocating on behalf of the person whose services and supports are being planned.

3400 Developing the Person-Centered Recovery Plan (PCRP) 

Revision 20-0; Effective August 25, 2020

An LMHA/LBHA must develop and revise, as needed, a person's PCRP. Each person's PCRP is developed through a person-centered process using ongoing discovery and input from all the people involved. Changes in the PCRP may or may not include changes in MI specialized services.  In the event there are changes in MI specialized services, the LMHA/LBHA must initiate an LA update meeting. 

The PCRP identifies a person's goals, strengths, preferences and clinical needs, as well as other support needs and desired outcomes. This information is gathered through discovery and information from other sources, such as:

• PASRR evaluation;
• Records from the NF and previous providers;
• Clinical Management for Behavioral Health Services (CMBHS) data warehouse;
• Mental and Behavioral Health Outpatient Warehouse (MBOW), CARE (e.g., diagnostic data, previous LMHA/LBHA services); and
• Previous individual recovery plans.

The PCRP identifies the services and supports that are needed to meet the person's needs, achieve the desired outcomes and maximize the person's ability to live successfully in the most integrated setting possible. The PCRP must include all specialized services agreed upon during an IDT or LA update meeting, including the person's desired outcomes.

At a minimum, for each MI specialized service agreed upon during the IDT or LA update meeting, the PCRP must indicate the amount, frequency and duration of the specialized service to be provided.

Information and training for person-centered recovery planning can be found at: https://centralizedtraining.com/. 

3410 Sharing the PCRP

Revision 20-0; Effective August 25, 2020

An LMHA/LBHA is responsible for providing a copy of the current PCRP to the person being served, or their LAR, and to the NF for placement in the person's medical record. A copy can also be given upon request to the LIDDA for people who are PASRR positive for both MI and IDD.

3500 Initiation of Specialized Services

Revision 20-0; Effective August 25, 2020

The LMHA/LBHA will begin providing needed MI specialized services following the IDT meeting.  TAC 26, Chapter 303, Section 303.301, allows the LMHA/LBHA 20 business days after the IDT meeting to begin initiation of specialized services.  

Before providing PASRR MI specialized services, completion of the UA and PCRP are required.  Therefore, the PCSP form for the IDT should document a UA and PCRP is agreed to by the team. Once the UA and PCRP are completed, an LA update meeting convened by the LMHA/LBHA will be held to discuss recommended specialized services. The LMHA/LBHA will document the LA update meeting on the PCSP form.

For people with dual diagnosis only, if funding for NF specialized services is available (i.e., Medicaid), the NF is responsible for the successful submission of a complete and accurate prior authorization request for NF specialized services in the Long Term Care Online Portal (LTCOP) within 20 business days after the date of the IDT meeting and must start providing a habilitative therapy service within three business days after receiving approval from HHSC in the LTCOP. Additionally, the NF must:

• order all durable medical equipment devices and customized manual wheelchairs in accordance with NF rules in 40 TAC §19.2754(e);
• provide ongoing habilitative therapy services, as approved by HHSC; and
• document annually on the PCSP form in the LTCOP all NF specialized services, IDD habilitative specialized services and MI specialized services being provided to a person.

When a person who is dually diagnosed PASRR positive for MI and ID/DD, the habilitation coordinator will be the lead in coordination of all specialized services. This requires the habilitation coordinator to work with the mental health case manager to coordinate MI specialized services and activities with the LIDDA specialized services.

3510 Eligibility for MI Specialized Services 

Revision 20-0; Effective August 25, 2020

A person who is determined to be PASRR positive for MI (has a serious mental illness, as defined in 42 Code of Federal Regulations §483.102(b)(1)) with Medicaid is eligible for MI specialized services. A list of MI services is found in Section 3530, Providing MI Specialized Services.

PASRR specialized services funded through Medicaid and other funding sources (if the person is not Medicaid-eligible at the time of the IDT meeting) should be discussed during the IDT meeting. Funding sources other than Medicaid for persons over 21 years of age should be recorded in the comment section of the PCSP form (field A3200).

3520 Authorization of MI Specialized Services

Revision 20-0; Effective August 25, 2020

All specialized services agreed upon during the LA update meeting will be authorized by the LMHA's/LBHA's Utilization Management department. Any changes in needed services after authorization is complete requires an updated uniform assessment, as well as an updated PCRP, to include the additional specialized services. In the event there is a change in specialized services, the QMHP-CS must convene an LA update meeting as soon as possible with all required team members in accordance with Section 3600, Local Authority (LA) Update Meetings.

See the Texas Resilience and Recovery Utilization Management (UM) Guidelines and the Utilization Management Program Manual at: https://hhs.texas.gov/doing-business-hhs/provider-portals/behavioral-health-services-providers/behavioral-health-provider-resources/utilization-management-guidelines-manual.

3530 Providing MI Specialized Services

Revision 20-0; Effective August 25, 2020

MI specialized services funded through Medicaid include:

• Group Skills Training;
• Individual Skills Training;
• Intensive Case Management;
• Medication Training (Group);
• Medication Training (Individual);
• Medication Training and Support Services (Group);
• Medication Training and Support Services (Individual);
• Psychiatric Diagnostic Interview Examination;
• Psychosocial Rehabilitative Services (Group);
• Psychosocial Rehabilitative Services (Individual);
• Routine Case Management;
• Skills Training and Development (Group); and
• Skills Training and Development (Individual).

Additional MI specialized services include:

• Cognitive Processing Therapy;
• Counseling Services (CBT – Individual or Group);
• Crisis Intervention Services;
• Peer Support; 
• Pharmacological Management;
• Screening Brief Intervention and Referral to Treatment (SBIRT) Screening – Brief Intervention Not Provided; and
• SBIRT Screening – Brief Intervention Provided.

The LMHA's/LBHA's QMHP-CS provides ongoing MI specialized services in accordance with the TRR Adult Utilization Management Guidelines. The services provided may change as the person's needs change or goals are more fully realized.

3540 Frequency and Duration of MI Specialized Services

Revision 20-0; Effective August 25, 2020

The eligibility for MI specialized services is "while the person is residing in the nursing facility." The frequency and duration of MI specialized services is determined by the PCRP in accordance with Adult Utilization Management Guidelines and the person's needs. Should the needs change, the LMHA/LBHA must conduct an updated uniform assessment and revise the PCRP. Following that, the LMHA/LBHA must initiate a PASRR LA update meeting with the appropriate attendees.

3550 Required Face-to-Face Encounters

Revision 20-0; Effective August 25, 2020

The LMHA/LBHA staff, who must be at least a QMHP-CS, meets face-to-face with a person as often as indicated in the PCRP to meet the person's needs. Based on personal need and the services provided, the frequency of face-to-face encounters will be one of the recommendations the QMHP-CS will make to the IDT. 

Face-to-face meetings with the person must include the provision of the services and supports described in this section.

3560 Accessing Other Needed Programs

Revision 20-0; Effective August 25, 2020

The LMHA/LBHA must assist a person to access needed specialized services and other needed programs and services that can provide supports and services to address the person's needs and achieve outcomes identified in the PCRP.

3570 Assess and Reassess Service Needs

Revision 20-0; Effective August 25, 2020

The LMHA/LBHA staff must continually assess and reassess a person's service needs by gathering information from the person and other appropriate sources, such as the LAR, family members, social workers, NF and other service providers, to determine the person's service needs and the specialized services that will address those needs.

• People admitted to a TRR level of care (LOC) must be reassessed periodically regardless of the LOC they have been admitted to.  
• A person who is PASRR positive and meets admission criteria to the LMHA/LBHA may be admitted to an LOC once the ANSA tool is completed and indicates a recommended LOC.  
• A person receiving MI specialized services must be reassessed every 180 days, although they can be reassessed at any time based on need.  

3600 Local Authority (LA) Update Meetings

Revision 20-0; Effective August 25, 2020

LMHA/LBHA staff must convene an LA update meeting when:

• the UA and PCRP are completed after the IDT meeting. This allows the person and/or their LAR to review results of the UA and PCRP with the LMHA/LBHA staff and a representative from the NF and the LIDDA in the case of a person who is PASSR positive and dually diagnosed;
• the person has become eligible for Medicaid-funded specialized services; 
• a change in condition affects the services being provided;
• there is a need, an outcome or goal that was not previously identified;
• an updated or new uniform assessment is completed;
• the person decides they no longer want MI services;
• the person transitions to the community; or 
• the person is discharged or deceased.

Within three days after an LA update meeting, the LMHA/LBHA must enter into the LTC online portal all required information on the PCSP form, as well as maintain a paper copy in the LMHA's/LBHA's permanent medical record.

3610 Required Members for LA Update Meetings

Revision 20-0; Effective August 25, 2020

The required members for LA update meetings depends on the reason for the meeting. Reasons for updates include a change in the person's medical condition or specialized services.

LA Update Meetings with Reason Code 1 or 2 

1. Change in the person's medical condition.
2. Change in specialized services.

Required members include the person or LAR, LIDDA and/or LMHA/LBHA depending on PASRR condition, habilitation coordinator (if assigned), an NF staff member who knows the person best (may be an RN) and providers of specialized services (except for durable medical equipment (DME) providers).

LA Update Meetings with Reason Code 3, 4, 5, 6, 7 or 8.

These meetings are held when the person:

1. Is deceased.
2. Is discharged from the NF.
3. Refuses habilitation coordination.
4. Transfers to another NF.
5. Transitions to the community.
6. Refuses MI specializes services.

Because these reason codes are used to document events that took place and affect a person's specialized services, convening the entire team is not always necessary. 

3700 Convening a Team Meeting When a Person/LAR Refuses to Attend

Revision 20-0; Effective August 25, 2020

When an LMHA/LBHA receives information that the person or LAR will not attend a scheduled IDT or LA update meeting:

• Offer to reschedule the IDT or LA update meeting. Ask the person or LAR for a date and time that is preferable for them and work with them to reschedule.
• Provide adequate notice of the meeting. Adequate notice may mean something different to each person/LAR. An LAR may need several weeks' notice. For a person who is anxious about the IDT or LA update meeting preparations, one hour may be adequate notice.
• Offer to change the location of the IDT or LA update meeting. A person may prefer the meeting in their room instead of a conference room.
• Offer the person or LAR the opportunity to participate by phone.
• Offer to have other IDT members participate by phone if the meeting is too crowded for the person or LAR. 
• If a person or LAR states that the IDT or LA update meeting should proceed without him or her, the LMHA/LBHA must find out what topics he or she wants discussed at the meeting and afterward share with the person or LAR a summary of the discussion and the results of meeting.
• If a person absolutely refuses to attend or participate in IDT meetings, the NF must initiate a discussion about why the person refuses to attend or participate. The IDT members must attempt to identify and resolve barriers.