1 cbhi services kickoff meeting september 9, 20091 in-home therapy (iht) overview performance...

1CBHI Services Kickoff Meeting

September 9, 2009 1

In-Home Therapy (IHT)

• Overview

• Performance Specifications

• Medical Necessity Criteria on MCE website

• Anne Pelletier-Parker– Massachusetts Behavioral Health Partnership


September 9, 2009 22

In-Home Therapy Services In Home Therapy Services is a structured,

consistent, strength-based therapeutic relationship between a licensed clinician and the youth and family for the purpose of treating the youth’s behavioral health needs. Services are delivered by one or more members of a team consisting of professional and paraprofessional staff, offering a combination of medically necessary:

In-Home Therapy

&

Therapeutic Training and Support.



In-Home Therapy Services



The In-Home Therapy Services provider:

operates from 8 a.m. to 8 p.m seven days per week, 365 days per year;

has 24-hour urgent response 365 days a year;

responds to all referrals telephonically within one business day;

responds to referrals during daytime operating hours by offering a face-to-face encounter within 24 hours.

engages in assertive outreach regarding engaging in the service

engages and supports the ESP/Mobile Crisis Intervention team in an emergency.



In Home Therapy Services may be provided in any setting where the youth is naturally located, including, but not limited to,

the home (including foster homes and therapeutic foster homes),

schools,

child care centers,

respite settings,

other community settings.



Intake In-Home Therapy Services provider

participates in discharge planning at the referring provider location;

makes every effort to meet at the time of referral or as soon as possible if the referral is initiated by the MCI Team as a diversion from out of home placement or psychiatric hospitalization;

will visit the youth and family in any safe setting within 24 hours of referral from an inpatient unit, CBAT, Crisis Stabilization or Mobile Crisis Team;

completes an initial, or updates an existing, risk management/safety plan during intake.



Initial Assessment

The In-Home Therapy Services provider completes an initial assessment within 24 hours of meeting with the youth and family.

Assessment includes:

main need /focal problem,

contributing factors to the main need from multiple life domains,

matching interventions with an emphasis on youth/family interactions and skill building.

The In-Home Therapy Services provider completes the age appropriate CANS-MA version within 48 hours of the initial contact.



Treatment Planning & Documentation

The In-Home Therapy Services provider, in consultation with the youth, the

parent(s)/guardian(s)/caregiver(s), IHT supervisors, other involved treaters, and

the IHT multidisciplinary team, completes an evidence-based/best-practice guided

treatment plan, including a risk management/safety plan, within seven (7)

calendar days of first contact. All parties involved, including the youth, sign the

treatment/care plan.

The In-Home Therapy Treatment Plan:

is solution-focused;

clearly defines interventions;

includes measurable outcomes;

assists the youth and family members in their environment to help the youth to

achieve and maintain stabilization;

is synchronized with other provider’s existing plans.



The In-Home Therapy team works with the entire family, or a subset of the family, to implement focused interventions and behavioral techniques to:



problem-solving

limit-setting

effective patterns of interaction

communication

risk management

/safety planning

Intensive Family Therapy may include working with the entire

family, or a subset of the family, to implement focused, structural,

strategic, or behavioral techniques, or evidence-based interventions to

enhance



The In-Home Therapy Services team employs a multidisciplinary model, with both professionals trained in working with youth and their families, and paraprofessional staff capable of providing family members with therapeutic support for behavioral health needs.

Staff are knowledgeable about: available community mental health and substance use disorder

services within their natural service area, the levels of care,relevant laws and regulations, Systems of Care philosophy and Wraparound planning process,medical, legal, emergency, and community services available to

the youth and family.

Staffing



Staff Supervision & Consultation

The In-Home Therapy Services provider ensures that a licensed, master’s level, senior clinician provides supervision commensurate with licensure level and consistent with credentialing criteria to professional and paraprofessional staff on a weekly basis.

A board-certified or board-eligible child psychiatrist or a child-trained Psychiatric Nurse Mental Health Clinical Specialist is available during normal business hours within one (1) hour for consultation related to treatment planning, medication concerns, and crisis intervention.

A senior-level, licensed clinician trained in working with youth is available to the staff and the supervisor 24 hours a day, seven days a week for consultation as needed.



Discharge Planning and Documentation

A discharge planning meeting is scheduled whenever the authorized

decision maker decides that services are no longer desired, or the

family, determines that the youth has met his/her goals and no longer

needs the service, or the youth no longer meets the medical necessity

criteria for In-Home Therapy.

Discharge plan includes, at minimum:identification of the youth’s needs according to life

domains,a list of services that are in place post-discharge and

providers arranged to deliver each service,

a list of prescribed medications, dosages, and possible side effects, treatment recommendations consistent with the service

plan of any involved state agency.



Eligibility

• All MassHealth benefit plans



FST enhanced and expanded to IHT

• For MassHealth, FST is being enhanced, expanded, and renamed In-Home Therapy

• MassHealth will no longer purchase FST beginning 11/1/2009

• FST will remain a viable service for the non-MassHealth population depending on specific insurer



IHT vs. FST: Similarities

• Home and Community Based Service• Comprehensive home based assessment and

CANS• Risk Management/Safety Planning• Treatment Planning and Monitoring of Goals• 24/7 Availability• Care/Case Management – collaboration with all

services and supports• Psychiatric Consultation to staff• Linkage with MCI and CSA teams• Behavioral Management/Parent Skills Training



IHT• Ongoing Treatment• Knowledge of Wraparound

and System of Care• 8 – 8, 365 Days• Hub for TM and IHBS• Professional and

paraprofessional team supervised by licensed, master’s level clinician

FST• Stabilization• Not required

• 9 – 5, M thru F• Not hub for other services• Master’s level and BA

level team

IHT vs. FST: Differences



IHT Authorization Parameters

• 15 minute units

• 360 units in 90 days (13 weeks)

• MCE specific document at end of day

21

In-Home Therapy Services

Worcester, MassachusettsSeptember 9, 2009

Rick Shepler, Ph.D., PCC-SCenter for Innovative Practices a part of the

Institute for the Study and Prevention of ViolenceKent State University

All materials copyrighted 2009,Richard Shepler, Ph.D

22

In-Home Therapy

• Either a Master’s level clinician or a team approach

• Intensive family therapy in the home or other community/natural setting to: – Enhance problem-solving, limit-setting

communication – Build skills to strengthen the family – Identify and utilize community resources – Develop and maintain natural supports – Risk management/safety planning


23

In-Home Therapy, con’t• Includes:

– Assessment (comprehensive home-based, inclusive of CANS)

– Development of a youth- and family-centered treatment plan – Intensive Family Therapy – Coaching– Skills training– Referral and linkage– Identification of community resources and development of

natural supports

• Available to MassHealth enrolled youth


24

In-Home Therapy (IHT): Pivotal service in a comprehensive system of

care

• IHT expands the continuum of care to increase the availability of the less restrictive service options for youth at-risk of out-of-home placement due to issues related to his or her mental health


25

Continuum of Service Intensity

• A continuum of intensity based on mental health needs of the youth

• Opens up range of youth to be served


26

Typical Youth/Family Served

• Youth with serious emotional challenges with functional impairments

• Youth at-risk of placement or have significant safety issues

• Youth with multiple system involvement

• System has not engaged youth and family effectively


27

Typical Youth Served

• Multiple risk factors

• Few protective factors

• Skill set deficits: e.g. problem solving; communication; emotional regulation

• Youth who need additional supports, active facilitation, and accommodations for success (school, home, community)


28

Parents and Families

• High in stressors – Low in resources and supports

• High family conflict

• Current parenting skill set unsuccessful in dealing with youth's mental health needs

• Trust issues with the “system”

• Difficulty with service access (work, transportation, poverty)


29

IHT Benefits: Youth and Families

• Reduced out of home placements

• Mental health stabilization

• Family Stability

• Reduced involvement in Juvenile Justice System

• Increased school success


30

IHT Benefits: Other Systems

• IHT actively assesses and manages risk and safety concerns

• Cost savings to other systems

• Increases positive outcomes for other child-serving systems (school success; decreased arrest rates, decreased abuse and neglect, etc.)


31

Differences Between IHT & Traditional Services

IHTServices delivered in the home and

community24/7 availability & response by IHT

team

Frequency & duration matches need

Flexible Scheduling

Lead role in service coordination

Smaller caseloads Comprehensive mix of services

OutpatientClinic-based

No 24/7 availability by team

One hour weekly appointments

Appointments during office hours

Limited opportunities for collaboration

Large Caseloads >30Therapy only


32

IHT: Key Components

1. Access and availability2. Eco-systemic assessment and intervention3. Intensity of service matches family need4. Active risk management and safety planning 5. Active intervention monitoring 6. Active support to family7. Respectful and culturally mindful

engagement8. Cross-system collaboration and advocacy9. Supervisor availability and team consultation All materials copyrighted 2009,

Richard Shepler, Ph.D

33

IHT: Service of Access• Service delivered where the youth lives and functions: home,

school, and community at times that are convenient to the family

• Access to information – Family dynamics and interactional patterns– Recovery environments

• Access to people– Family – School– Court– Community– Informal supports

• Access for interventions: implemented where behaviors occurAll materials copyrighted 2009,


34

Ecosystemic Assessment and Intervention

• Behavioral health interventions that impact the youth in context of his or her functional environments – Home– School– Peers– Community


35

Intensity of Service Matches Family Need

• Based on youth and family need and functional impairment

• Caseload size should reflect program intensity:

The greater the need the greater intensity the smaller the caseload


36

Active Risk Management & Safety Planning

• Active risk management; safety assessment, planning and monitoring

• Family is involved and informed

• 24/7 on call: The In-Home Therapy Services provider has 24 hour urgent response accessible by phone to the youth and family, 365 days a year.

• Immediate crisis response from In-Home Therapists with face to face response as needed


37

Active Intervention Monitoring

• IHT actively monitors interventions

• Treatment persistence


38

Active Supports

• Resource poor and resource drained families

• Pile up of stressors and life circumstances

• Need active system support until we can re-build informal supports


39

Respectful and Culturally Mindful Engagement

• Appreciative perspective: Families are doing the best they can do, at any given time, given their current capacities and abilities, and life circumstances.

• Strengths and Culture Discovery (VanDenBerg): IHT providers strive to understand and appreciate the family’s values, culture, strengths, and life realities.

• Validation and Valuing: The youth and family are validated for their courage, efforts, and persistence, knowing that progress is sometimes very difficult, and that “hanging in there” is sometimes all that is possible at any given point in a family’s life. (Resiliency Ohio, 2008)


40

Partnering with Youth & Families

• The whole is greater than the sum of its parts. Working together accomplishes more than working apart

• We need to pool our resources and expertise

• Mutual Expertise: Youth and families are experts on their lives and you are an expert in your field.

• Engage parents and young adults in transition as co-consultants


41

IHT Lessons Learned: Engagement

• Mutual assessment process: youth and families are assessing us as we are assessing them

• Misinterpreting a family’s self protection as resistance

• Public testimony versus private testimony


42

Cross-system Collaboration and Advocacy

• Pro-active cross-system collaboration and service coordination

• Skillful advocacy efforts are promoted to assist with accommodations and system navigation - while respecting other child-serving system’s mandates


43

Supervisory Support, Availability and Team Consultation

• Access and availability for IHT staff when needed

• Pro-active consultation and strong clinical support

• Supervisor should have a designated responsibility to the team


44

Phases of Home-based Intervention

Engagement and Assessment• Engagement (youth, family, & collaborative partners)• Risk Management and Safety Planning• Assessment

Treatment• Individual and family treatments and supports• Skill Building, Skill Consolidation, and Generalization

Enhancement of Positive Support Network • Linkages, Closure, & Follow-up

Discharge• In Ohio the average LOS for Intensive Home-Based Treatment is 4.5 months


45

Multidimensional Assessment

I. Diagnoses: youth who meet the criteria for Mental Health Disorder and related symptom manifestation

II. Developmental Functioning: (cognitive, emotional, & behavioral maturity)

III. Contextual Functioning: Individual functioning in relevant life domains, including risk and protective factors, and risk and recovery environments

IV. Safety Risks: Self and other harm, personal, family, and community safety


46

Comprehensive Array of Services:IHT Core Services

• Risk management and safety planning

• Skill building

• Individual & Family Interventions

• Cross-System Interventions and Service Coordination

• Resource and support building activities


47

Organizational Framework

• Need framework for organizing the myriad of information obtained in the home environment

• A family need hierarchy is utilized to assist in assessing and prioritizing the youth’s and family needs

• Strategies and interventions are matched to the most salient need, progressing to more complex needs once the primary needs are met


48

FAMILY NEED HIERARCHY R. Shepler (1991;1999)

Recovery & Resiliency

ECOSYSTEMIC FUNCTIONING

BASIC SKILLS

BASIC NEEDS & SAFETY


49

Basic Needs, Safety, and Stabilization

• Are there material needs that are unmet? (Food; Shelter)

• Are there current safety and/or symptom concerns that need stabilization?

• Are there significant risk factors that are barriers to recovery?


50

Basic Needs and Safety (con.)

Assist with basic needs: Active Case Management and Advocacy

Establish basic safety: Risk management; safety planning; symptom stabilization

Risk reduction: Reduce risk factors and environmental stressors.


51

Basic Skills

• Does the youth and family know how to do what you are asking them to do?

• What skills does the youth need to be successful?


52

Skill Set Development

• Emotional regulation skills (CBT; DBT; ART; etc)

• Communication skills: individual and family

• Conflict management skills: Negotiation, compromise, problem solving skills: conflict resolution; mediation

• Self knowledge: Triggers; symptom management

• Personal safety skills


53

Ecosystemic Functioning

• What family or system dynamics are barriers to the youth and family’s success?

• How well does the youth function in key life domains/ (home, school, peers, community)

• Goal: Improve functioning in major life contexts (family, school, community, social, vocational, etc)


54

Family Context: Set Stage for Change

• Create family recovery environment

• Decrease family conflicts

• Rebuild bonds and relationships

• Increase positive family communication

• Increase supervision and monitoring


55

Community Context: Building Connections

• Educate community professionals (schools, juvenile court, children services, etc) on the impacts of mental health challenges

• Facilitate reasonable expectations

• Facilitate accommodations

• Facilitate connections and opportunities


56

Recovery and Resiliency

• What resources and supports are necessary for ongoing growth and development?

Empowered parents Supports: informal and formal; for youth and family Positive peers and activities Mentors Pro-social activities Positive connections (School; community) Opportunities to give back Services:

• Wraparound process: ICC• Possible step-down services: therapeutic mentoring• Medications; Psychiatrist


57

IHT Discharge

• When to discharge:– Presenting mental health symptoms no longer

causing functional impairments – Child no longer at-risk of placement– Safety issues are stabilized– Treatment gains have reached a plateau– Family voice and choice– Youth needs higher level of care for safety– Treatment plan goals have been met


58

Lessons Learned: IHT Discharge

• Common Issues: – Difficult for family to let go of valued service – Pressures from community to remain involved– No viable step-down options– Family crises at termination or as services wind down – There is still lots of work to do

• Keep in mind:– Medicaid pays for episodes of treatment– IHT is based on medical necessity and therefore is

typically time limited


59

Common Concerns and Challenges

• Bugs• Contagion• Animals• Weapons• Neighborhoods• Distractions: phones; TV; visitors

• Getting comfortable so you can do the work• Need to adopt standard safety precautions


60

Lessons Learned: Managing Challenges

• Remember you are a guest in family’s home• You are in control of the mental health service.

The family is in control of their home.• Be respectful of the family’s values and culture• Do not demand or challenge. Make simple

request if needed.• Relate to the family how the challenging

situation affects you and what would be helpful.


61

Lessons Learned from the Field

• Engagement is key

• Confidentiality in the field

• Reporting obligations

• Where to do sessions

• Transporting


62

Lessons Learned: Administrative Supervision

• Don’t let administrative supervision (productivity and paperwork) take time away for clinical supervision and case consultation time

• Managing caseloads and LOS

• Protecting electronic information– Client communications via internet– Texting

• Traveling with information

• Managing ethical situationsAll materials copyrighted 2009,


63

Lessons Learned: Implementation

• Build policies that support the worker: – Dedicated supervisor– Cell phones– Flex-time policies– Flex funds when possible– Adjusted productivity expectations – Policies and trainings that support worker safety ,

ethics, and burnout

• Ongoing coaching and training• Supervisor with previous in-home experience is

criticalAll materials copyrighted 2009,


64

Lessons Learned: Implementation

• Clearly identify the target population and where your service fits into the overall continuum of care in your community

• What stakeholders need to be on board…who are the champions and what do they expect

• Significant community wide education about the program

• Be careful of the overpromise• Identifying and maintaining key referral sources• Plan and budget for turnover


65

The Critical Equation NIRN

Effective intervention practices and programs

+

Effective implementation practices

=

Good outcomes for children and their families

No other combination of factors reliably produces desired outcomes for children, families, and caregivers


66

Contact Information

• Rick Shepler, Ph.D., PCC-S

330-806-6976

[email protected]


1 cbhi services kickoff meeting september 9, 20091 in-home therapy (iht) overview performance...

Documents

therapy services slide

cbhi services kickoff

hours of meeting

hours of referral

initial assessment

treatment setting

home placement

referring provider location