File Review Learning Lab

Experience Matters!Valerie Cherry, PhD, Lead Mental Health SpecialistHelena Mackenzie, PhD, Region V Mental Health

SpecialistFacilitator: Melissa Cusey, RN, Nurse Specialist

Learning Lab

Groups of six individuals each (ideally with a CMHC in each group)

Each group has: Leader: directs action for session Recorder: writes for the group Reporter: shares the group’s work/reports out

Help each other learn the process and practice!

Identify one challenge you have with the file review process.

List one personal objective for this lab.

Objectives

Describe the requirements and processes of the file review team, direct threat and health care needs assessments.

Understand your role in the file review, direct threat and health care needs assessments.

Complete thorough file reviews with clear documented summaries.

Gain confidence through writing appropriate direct threat and health care needs assessments with peers.

Changes With New PRH Chapter One…

What is the same? What has changed?

Essential Admission Requirements (EARS)

Prior to conditional enrollment, OA assesses eligibility using EARS: Criterion I: Program Suitability (Education and

training needs) Criterion J: Group Participation & Understanding

Rules (participate successfully in group situation) Criterion K: Interference with Other Students’

Participation

(only EARS impacting center recommendations listed)

Once Eligible…

ETA 6-53 & health documentation reviewed to determine whether JC can meet applicant health needs

If indicated, Health and Wellness staff review file, noting areas of potential concern (File Review Summary)

FRT, including relevant health and wellness staff, interviews applicant and considers whether JC appropriate

How does the File Review Team

determine if JC is an appropriate

setting?

Additional Steps…

If applicant has disability, the RAC also interviews applicant and identifies accommodations, with input from applicant

FRT re-reviews file to see if concerns are ameliorated with identified accommodations

File is forwarded to Center Director, who completes “reasonableness” determination (if indicated) and forwards file to Region

Recommendation for Denial at Center Level:

Two Primary Reasons to Recommend Denial: Concern applicant is at significant risk of harming

self or others Complete Direct Threat Assessment

Believe JC can not meet applicant’s health care needs Complete Health Care Needs Assessment

Third (Rare) Reason to Recommend Denial: New Information

Revisit specific EAR

Health Care Needs

Health care needs beyond JC basic health care responsibilities

Red Flags: Frequent recent ER

visits Newly diagnosed or

uncontrolled health issue

Symptoms/condition not well managed in similar environment as JC

Require extensive resources/intervention

Direct Threat

Significant risk of substantial harm

Threat is imminent: current specific behaviors, symptoms indicating instability

Burden is on JC to prove direct threat exists

With disability, must consider whether accommodations decrease threat to acceptable level

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Proposed Appendix 610Health Care Needs Assessment

A health care needs assessment should be completed whenever Job Corps believes that the health care needs of an applicant are beyond what the Job Corps’ Health and Wellness program can provide as defined as basic health care in PRH Exhibit 6-4: Job Corps Basic Health Care Responsibilities.

This typically will occur after the applicant has received conditional assignment to a Job Corps center and has completed the 6-53 Health Questionnaire. Applicant has health care needs beyond basic health services as

defined in PRH 6 Exhibit 6-4.

Barriers to meeting health care needs cannot be eliminated or reduced by reasonable accommodation or modification.

Indicators for a Health

Care Needs Assessment? Two or more ER visits or one or more hospitalizations

for medical, mental health, oral health, and/or substance abuse reasons.

New diagnosis or recurrence of medical, mental health, extensive untreated oral health, and/or substance abuse condition that would require frequent medication adjustments, significant health resources and/or substantial change to the training day.

Failure to follow previous treatment recommendations by licensed health providers that has adversely affected the applicant’s health, behavior, and/or adaptive functioning, and now requires significant health care management.

Indicators for a Health

Care Needs Assessment?

Applicant has followed treatment recommendations by licensed health providers with no improvement in applicant’s health, behavior, and/or adaptive functioning which continue to place applicant in need of significant health care management.

Applicant’s condition or behavior has not been successfully managed in a similar academic, work, or group environment in the past year.

Applicant is in treatment for a condition that is not in the scope of Job Corps Basic Health Care Responsibilities (e.g., orthodontic braces for malocclusion).

Health Care Barriers

Frequency and length of treatment

Severe medication side effects

Hourly monitoring required

Medical needs requiring specialized treatment

Therapeutic milieu required

Complex full mouth reconstruction or rehabilitation

Complex behavior management system beyond Job Corps current system

Out-of-state insurance impacting access to required and necessary health care

Daily assistance with daily living skills [Other (specify)]

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Review ProcessHealth Care Needs Assessment

The review should, at a minimum, be comprised of the following elements: A review of specific condition(s) identified on ETA 6-

53, or self-disclosed by applicant. Review of health documentation in the file. Request additional recent health information, to

determine applicant needs, if appropriate and medically necessary. Collaborate with OA counselor.

Documented communication with treating provider, if possible and required if there are conflicting recommendations between the center health consultant and the treating provider.

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Review ProcessHealth Care Needs Assessment

Interview with applicant, and parent/guardian if a minor, either face to face, videoconferencing, or via telephone. If unable to contact applicant, all attempts need to be clearly documented including collaboration with OA counselor.

If condition rises to a level of a disability then refer to the reasonable accommodation committee (RAC) for consideration of accommodations and/or modifications for discussion with applicant. See Appendix 605 for definition of a disability.

Consider if accommodations and/or modifications would remove the barriers to enrollment and make condition manageable at Job Corps as defined by basic health services in PRH Exhibit 6-4.

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Decision TreeHealth Care Needs Assessment

Health care needs manageable at Job Corps as defined by basic health care services in PRH Exhibit 6-4, but may require community support services to be in place on entry due to special care needs (e.g., on-going community mental health treatment, specialized provider, etc.) to ensure continuity of care. Community support services available near center.

Community support not available near requested center Documentation of efforts to arrange for less frequent treatment in

home state and to secure community support near requested center should be included in the file (i.e., name of organizations/facilities and specific individual contacted).

File is forwarded to Regional Office for final determination

Decision TreeHealth Care Needs Assessment

Health care needs exceed basic health care as defined in PRH Exhibit 6-4. Applicant has health condition with current

symptoms at a level that will interfere with successful participation in the program at this time. Deny entry and refer to other appropriate program/provider.

Files forwarded to the Regional Office

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Decision TreeHealth Care Needs Assessment

Accommodations or Modifications If the individual is a person with a disability, the

center’s reasonable accommodation committee (RAC) must convene and consider and discuss with applicant accommodations and/or modifications that the individual may need. Once the accommodations and/or modifications have been identified, the qualified licensed professional who conducted the original assessment must review the previous findings giving consideration to the identified accommodations to determine whether or not the accommodations and/or modifications can remove the barriers to enrollment due to health care needs.

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Decision TreeHealth Care Needs AssessmentCenter Director Reasonableness

Determination

If the individual is a person with a disability and accommodations or modifications that could remove the barriers to enrollment due to health care needs have been listed by the center’s reasonable accommodation committee (RAC), the Center Director is responsible for making a determination as to whether such accommodations or modifications would be “reasonable” or pose an undue hardship and if so, she/he will then recommend denial of the accommodation to the Regional Office.

Health Care Needs(HCN)Large Group Practice I

During the center file review process you receive the following: In the confidential health envelope, the 6-53 indicates an

applicant who has received mental health treatment in the past and diagnosis of bipolar. There is a summary from group home that indicates applicant was terminated 3 months ago due to not following rules and engaging in arguments and fights with members in the group home. CCMP indicates applicant is noncompliant with medication and prognosis is poor without medication. Indicates applicant can attend Job Corps with weekly counseling and weekly psychiatric follow-up. Applicant has state funded insurance and is applying to center out of state.

1. HCN: What Factors Triggered Review of the File For a HCN

Assessment?

Failure to follow previous treatment recommendations by licensed health providers that has adversely affected the applicant’s health, behavior, and/or adaptive functioning, and now requires significant health care management.

Applicant’s condition or behavior has not been successfully managed in a similar academic, work, or group environment in the past year.

2. What is applicant’s history and present functioning to support

statement of HCN? File Review

ETA 6-53 (Health Questionnaire)- Indicates this 17 year old applicant has a diagnosis of bipolar and is receiving weekly mental health and medication management. Applicant also checked “lost control of your anger, or feared losing control of your anger, to the point of hurting yourself or someone else?”

Applicant File Review Summary (Brief summary of relevant information from medical records, IEP, school records, etc.) -Three months ago was terminated from group home due to unpredictable behavior resulting in verbal altercations with staff and 2 fights with group members. Mental health assessment two months described as having a “serious” level of impairment and needs to “improve ability to cope with stressors to decrease mood swings and aggressive behaviors.” Specific symptoms within the last three months include: uncontrolled cycling behavior, poor relationships with others, difficulty sleeping, decreased motivation, and refusal to comply with “authority figures.

Health Care Needs (HCN)

Large Group Practice IFile Review (continued):

CCMP Provider Form (Recommend JC?): Yes-The treating therapist indicated that applicant could likely participate in JC, as long as he was able to continue receiving weekly mental health treatment, medication management and additional support on center as needed. Because this recommendation appeared somewhat inconsistent with information in the applicant’s file and interview, a brief follow up call was made to the therapist on October 10th. During that call, the applicant’s therapist expressed concern that applicant would have difficulty living in the dormitory as he becomes highly stressed and has “meltdowns” in social situations. Therapist also indicated that applicant is non-compliant with medications and there has been an increase in mood swings Therapist indicated applicant must receive on-going weekly treatment at a minimum in therapeutic milieu.

Health Care Needs (HCN)

Large Group Practice IFile Review (continued):

Applicant Interview Summary (Including clinical impression of applicant, e.g., mental status, behavioral observations, etc.) —The file review team, including the CMHC interviewed the applicant by telephone (he lives in another state and was unable to travel to center). The applicant acknowledged ongoing difficulty with emotional dysregulation and outbursts, but felt that he would be much happier “away from home.” Applicant currently reports feeling depressed, social withdrawal, and a lack of motivation. According to applicant he was doing better when he was on meds, but discontinued because he doesn’t like taking medicines. He seemed anxious during the phone call and became easily irritated when asked questions about specific mental health symptoms (particularly related to the cycling behavior); however, he answered all questions.

3. HCN: What are the Health Care Management Needs that are Barriers

to Enrollment?

Frequency and length of treatment

Severe medication side effects

Hourly monitoring required

Medical needs requiring specialized treatment

Therapeutic milieu required

Complex full mouth reconstruction/rehabilitation

Complex behavior management system beyond Job Corps current system

Out of state insurance impacting access to required and necessary health care

Daily assistance with daily living skills

Other (specify)

4. HCN: Does the Applicant Have Health Care Needs Beyond What the

Job Corps’ Health and Wellness Program Can Provide?

Applicant has health condition with current symptoms at a level that will interfere with successful participation in the program at this time. Deny entry and refer to other appropriate program/provider

File is forwarded to Regional Office for final determination.

5. HCN: If Student has Disability, RAC Must List Any Accommodations or Modifications

Discussed with the Applicant That Could Remove or Reduce the Barriers to Enrollment

1. Adjust schedule to allow him to attend therapy and psychiatry appointments off center, if available in the community

2. Set breaks during the day and encouraged to touch base with designated supports during those times if needed

3. Provided with room in smaller dormitory

After review of assessment considering the accommodations/modifications listed above, the barriers to enrollment can be eliminated or sufficiently reduced to allow for the applicant’s health care needs to be managed at JC

X After review of assessment considering the accommodations/modifications listed above, the barriers to enrollment cannot be eliminated or sufficiently reduced to allow for the applicant’s health care needs to be managed at JC

AccommodationsModifications that will help student participate in program (not treat

impairment)

Accommodations: Distraction-free

space Modified schedule Frequent breaks Peer buddy/tutor Positive behavior

support Visual supports Single room/smaller

dorm

Case Management (not accommodations) Brief, periodic check-

ins with CMHC Medication

appointment Stress reduction group Participation in social

skills group Attend off-center

therapy

6. HCN: Center Director Only

If center recommends denial due to being unable to meet accommodations, CD must complete this final section Are accommodations reasonable or do

they pose undue hardship on center?

Direct Threat1. What Factors Triggered a Review of

Individual’s File for Direct Threat?

Direct Threat2. What is the

Nature/Severity of Potential Harm

1. What kind of harm is posed by the individual’s medical condition or disability?

2. What is the seriousness of the potential harm? (e.g., death, serious injury, minor emotional distress)

Direct Threat

3. What is the duration of the risk (e.g., how long will risk last)?

4. What is the likelihood that the potential harm will occur (e.g., high, moderate, low)?

5. What is the imminence of the potential harm (e.g., how soon likely to occur)?

Direct Threat

6. Based on factors above, does the named individual have a medical condition or disability that poses a significant risk of substantial harm to the safety of him/herself or of others if s/he participated, or continues to participate, in JC?

In my professional judgment, the individual’s participation poses a direct threat

In my professional judgment, the individual’s participation does not pose a direct threat

Direct Threat

7. List below any accommodations or modifications that could either eliminate the risk or reduce it to an acceptable level (** see next slide for examples)

1. 2. 3.

After review of the factors considering the accommodations/modifications listed above, the threat can be eliminated or reduced to a level below DT

After a review of the factors considering the accommodations/modification listed above, the threat cannot be eliminated or reduced to a level below DT

AccommodationsModifications that will help student participate in program (not treat

impairment)

Accommodations: Distraction-free space Modified schedule Frequent breaks Peer buddy/tutor Positive behavior

support Visual supports Single room/smaller

dorm Schedule adjustments

(leave class early; time out to attend off-center appt)

Case Management (not accommodations) Brief, periodic check-ins

with CMHC Meet with MD for

medication management

Educate student about stress reduction

Encourage participation in social skills group

Attend off-center therapy

Direct Threat

Center Director Only

8. If accommodations or modifications are listed in #7 above, you are responsible for making a determination as to whether such accommodations or modifications would be “reasonable” or pose an undue hardship. Document your determination on the space provided. Attach additional sheet or information if necessary.

PRACTICE! PRACTICE!Learning Lab Group Breakout

Learning Lab Practice

Groups of six individuals each

Identify (quickly): Leader: directs action for session Recorder: writes for the group Reporter: shares the group’s work/reports out

Direct Threat or Health Care Needs Assessment?**Quickly review two files at your table and determine which you think is most appropriate for DT and which for HCN? (5 minutes)**Check your decision with a group next to you (discuss if disagree)

Direct Threat Versus Health Care Needs?

Direct Threat: Imminence:

Immediate safety concern Suicidal behavior Homicidal behavior Impaired judgment Paranoid thinking Threat of assault

Health Care Needs May have safety issues

related to health needs, but threat is not imminent Mood swings Impulsive behavior Poor diabetes control

Complete Health Care Needs Assessment

As a group, work together to review data in file Jot down medical and other information

relevant to direct threat concern (two points from each source, e.g., 6-53, File Review Summary, CCMP, etc.).

Complete Health Care Needs Assessment as group

Objective: teach each other (each of you will have a unique perspective regarding how to approach task)

Complete process in approximately 15 minutes!

Complete Direct Threat Assessment

As a group, work together to review data in file Jot down medical and other information

relevant to direct threat concern (two points from each source, e.g.. 6-53, File Review Summary, CCMP, etc.).

Complete Direct Threat Assessment as group

Objective: teach each other (each of you will have a unique perspective regarding how to approach task)

Complete process in approximately 15 minutes!

Large Group Report Out

Reporter from each group will share a section from one of your assessments (e.g., nature and severity of potential harm, accommodations from DT, history/present functioning from HCN, etc.).

Large group will provide brief feedback on section shared, for instance: Are accommodations

clear? (and not case management)

Are important pieces of medical information included in HCN?

Is enough documentation provided to uphold recommendation for denial?

Process Feedback: Confidence RulerHow confident do you feel in your understanding of the file review process and your ability to complete (with input from relevant FRT members) Direct Threat and Health Care Needs Assessment?

On your notecard:

Identify one thing you want to do in the next month to increase your

confidence in this process…

Take your card with you!

FeedbackThank you for participating! Please complete your feedback

form before you go.