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Q and A: Integrated Services and Supports Rule

Questions from the ISSR webinar March 7, 2013

General Questions
Assessments
Individual Services and Support Plans
Licensed medical practitioners and their designees
Intensive community-based treatment services
Phase 2


General Questions

Q: Will a recording of this webinar be available online?

A: No. The presentation used in the webinar is available on the AMH website here.

Q: Why are the state’s Medicaid documentation standards different than those of OWITS (Oregon Web Infrastructure for Treatment Services), for example? It would seem that having the same standards would truly streamline our work.

A: The two are not really equivalent. ISSR, which governs the providers who deliver mental health and addiction services in Oregon, is a set of minimum standards that provide a baseline for clinical quality, health and safety, and Medicaid compliance. OWITS  is an optional, free electronic health record that the state makes available to providers. Many electronic health records (EHRs) likely will exceed ISSR’s minimum standards.

Q: Is it true that CMS does not recognize Oregon's definition of qualified mental health professional (QMHP) as a provider who can "prescribe"?

A: Yes. Federal regulations require that a person who recommends rehabilitative services be a physician or other licensed health care practitioner. See 42CFR440.130(d).

Q: Will Oregon’s Medicaid Payment administrative rules also be updated to match these requirements?

A: Oregon’s administrative rules on Medicaid payment (OAR 309-016) refer to the ISSR. Therefore, the Medicaid payment rule does not need to be updated to reflect changes in ISSR.


Assessments

Q: Can licensed medical practitioners (LMPs) update mental health assessments and individual service and support plans (ISSPs) in the same way that licensed mental health practitioners can?

A: Yes. An LMP meets the definition of a Licensed Health Care Practitioner for the purposes of the ISSR.

Q: Do the changes allow for a practitioner to complete a simple assessment and treatment plan and begin treatment in one session?

A: Yes, it is possible to create an assessment and a plan in one session so that treatment can begin immediately. The assessment and plan need to meet the ISSR requirements.

Q: Under the revised ISSR, can we now limit our initial assessment of an individual to those areas that are relevant to the problem for which the person is seeking treatment?

A: Yes. You do not need to include any information that is not relevant to the individual’s condition. Your assessment needs to include only enough information to justify the diagnoses.

Q: If I continually update a patient’s assessment and plan, does this meet the requirement that they be updated at least annually?

A: Yes, assessments and plans must be updated at least once a year. They can be updated more frequently and reimbursed when medically appropriate.

Q: As long as an assessment is signed by a QMHP, can it be in a clinical service note as opposed to being a stand-alone document?

A: Yes, the rule only prescribes the required content, not the format.

Q: I have heard that a clinician can bill for only one assessment code per year, regardless of how many times the assessment is updated. Is this true?

A: No. You can bill DMAP for as many assessments or plans per year as are medically appropriate. Each payer source may have its own rules.

Q: What are the signature requirements for initial assessments and updated assessments?

A: All assessments must be completed by a QMHP and signed by the QMHP.

Q: Can a child be assessed without direct face-to-face observation?

A: No. All assessments require direct face-to-face contact.

Q: I have heard a reference to “13 domains” in the context of data collection. Can you explain this reference?

A: This was a reference to pre-ISSR administrative rules. The current rules do not refer at all to any such domains.

Q: Why is ASAM PPC-2R (The American Society of Addiction Medicine Patient Placement Criteria Second Revised Edition) no longer used for outpatient addiction services?

A: The Oregon Health Authority stopped using these guidelines for outpatient addiction services when it revised the ISSR, as a way to better integrate the mental health and addiction assessment standards.  OHA Addictions and Mental Health (AMH) acknowledges the value of using ASAM PPC-2R. It encourages providers to decide at the program level whether to continue using it.

Q: Now that we have to include both addictions and mental health parts of an assessment in one document, what are the proper roles of QMHAs and QMHPs in the assessment and plan? After a recent MH site review, it was relayed that our current assessment (completed in parts) should be changed so the assessment is all in one document. If we are now including A/D and M/H portions in one document, we must have QMHPs administer the assessments. I know the QMHAs can "gather" information but not diagnose an MH disorder. But we can't have a QMHA do the assessment then pass it on to a QMHP for the diagnoses and summary because the QMHP will not have met the client and that does not seem ethical. Please provide your feedback on this.

A: An integrated plan is not required. Staff addressing the mental health, alcohol and other drug needs of the individual must meet the minimum requirements for each service type. For more information on the definitions of these provider types, see the QMHA-QMHP Frequently Asked Questions (FAQ).

Q: Do we have to do a complete new assessment of a client who comes to us from a different provider; for example, one who was in residential treatment covered by private insurance who is now covered by OHP and seeking outpatient treatment from us?

A: You can accept another provider’s assessment of a patient, but first you must actually meet with that patient to decide whether the previous assessment is still current and accurate. You must document that you met the patient face-to-face and that your treatment will be based on the other provider’s assessment. This assessment becomes your basis for delivering services.

Q: Does a psychiatric diagnostic interview qualify as an initial assessment and/or an annual update?

A: Yes, if it meets ISSR’s requirements for an assessment.

Q: What is the difference between the "decision tree" and the ASAM placement criteria relative to determining the appropriate level of care? Do you have an example of a decision tree?

A: AMH does not prescribe a particular decision tree format. The previous rule required the same level of documentation for patient placement, regardless of the level of care. Under ISSR, only higher levels of care require a certain level of documentation.

Q: Who has the final word on what is relevant in an assessment to substantiate a diagnosis?

A: If a provider exhausts their hearing and appeal rights, OHA or the courts would have the final say.

Q: As level I alcohol and drug assessments become more of a "screening," can new documents be created that are not ASAM based?

A: Neither AMH nor the ISSR prescribe forms to use for assessments. ISSR defines the requirements for assessments. Please note that a level 1 A&D assessment requires more than a “screening.”

Q: To whom does the new rule for streamlining level 1 assessments apply: those already in mental health services or those who are first time walk-ins for DUII services?

A: All assessments performed after ISSR became effective –Feb. 11, 2013 –  are subject to the updated rules.

Q: Last year we learned that our assessment needed to include a detailed risk assessment portion. Where does that requirement fit in now?

A: A risk screening is still required under ISSR. Each individual’s biopsychosocial information is unique; therefore, some individuals will need a more thorough risk assessment.

Q: Are there any exceptions – such as crisis, medication consultations or case management – to the requirement for an assessment before treatment begins?

A: No, there are no exceptions. You must perform an assessment before you provide any outpatient mental health or addiction treatment services to any individual.

Q: What is sufficient information to document medical necessity for treatment? If the provider can document that someone has met DSM criteria for a mental disorder, does that sufficiently establish medical necessity?

A: Medical necessity is established by providing the relevant information necessary to justify a diagnosis of a condition whose treatment is above the line on the Prioritized List.

Q: Does an annual assessment require physical health information?

A: No, an annual assessment does not require any specific “physical health information.  “However, a client’s assessment should be updated if there are substantial changes to his or her biopsychosocial information that would affect their behavioral health needs or diagnosis.

Q: Do assessments for residential alcohol and other drug treatment programs require additional information, such as a complete medical history, medication list, etc.?

A: An assessment must include all relevant biopsychosocial information. If information such as a complete medical history and medication list is relevant for the individual, it must be included.


Individual Service and Support Plans (ISSPs)

Q: As I understand it, an individual who is receiving both mental health and addiction services does not need to have a separate service plan (ISSP) for each type of service. Is the ISSP required to be integrated? What if a provider is only certified to provide mental health or addiction services?

A: No, the ISSP is not required to be integrated. A state-approved mental health program approved only for mental health services may only provide services intended to improve the mental health condition of the individual. If the program is approved for both, the individual providing a particular service must be a qualified provider of that service. For example, John Doe, CADC, would be approved to provide A&D services but not to run a group intended to improve their mental health condition.

Q: Does an ISSP need to document timelines?

A: No, timelines are not a required element of an ISSP.

Q: Does the client need to sign his or her service plan or updates?

A: No. The ISSR does not require a client signature on a service plan. However, providers must show that the client collaboratively participated in the plan’s development. Some providers use the client signature to show client participation.

Q: Does a service plan require documentation of frequency of services?

A: Yes. The rule states that frequency and duration of each service are among the details required in the plan. See OAR 309-032-1530 (2) (b) (C).

Q: Does an LMP need to approve the changes to a service plan if the plan’s goals or objectives change, but not the prescribed services?

A: No. The LMP is only required to sign the service plan annually.

Q: If a client does not come to our office for a year (365 days) following the intake assessment, are we required to complete the annual service plan update to show client collaboration?

A: No. If the individual is not engaged in services, you do not need document collaborative participation in the service planning process.

Q: Why was the option of a provisional service plan removed from our options? This seems to limit our opportunities to begin providing services quickly, because we have to implement a full ISSP, including client collaboration and consent, before we can start providing services.

A: The option of a provisional ISSP was eliminated because some providers reportedly thought that it only duplicated the “full” ISSP. The service plan must reflect the services that are going to be delivered. It can be brief as long as it reflects the individual’s needs. The provider can add to it as needed. But client collaboration and consent for services are required before the start of services. Involuntary treatment services are governed by a different set of administrative rules (309-033). 

Q: Can a counselor in training, who is technically not yet a CADC, sign an ISSP without CADC oversight?

A: Yes. ISSR allows for staff that become certified within two years of their first hire date and apply for certification within six months after certification. See 309-032-1520 (2) (c)


Licensed Medical Practitioners (LMPs) and their Designees

Q: Who can a licensed medical practitioner (LMP) designate to review an individual service and support plan (ISSP)? Should the designation be to a specific individual?  How should the designation be documented?

A: An LMP can delegate oversight to a licensed health care practitioner as defined by the ISSR. The delegation should be both client- and clinician-specific, rather than by blanket policy. For example, a provider should not designate LCSW John to review all cases for LMP Sue. This delegation is not intended to include any medical oversight of cases, nor does it relieve LMPs from the responsibility to review ISSPs annually.

Q: Does a qualified mental health practitioner (QMHP) need to be licensed to complete an assessment?

A: No, it is within the QMHP’s scope of practice and competency requirements to complete an assessment for mental health services.

Q: Since the LMP can designate oversight authority to a licensed health care practitioner (LHP), can the LHP sign the annual ISSP?

A: No. The LMP must sign the service plan annually. Changes made to the plan during the year may be delegated.

Q: Why is a QMHP the only one who can be delegated to sign an assessment without LMP review?

A: QMHPs by definition have the competency to conduct an assessment, complete a diagnosis and supervise the implementation of the service plan.

Q: Does an LMP need to sign the service plan every year for clients who are receiving only addiction services?

A: No. Services intended to improve the individual’s alcohol or other drug-related condition do not require documented approval of an LMP.

Q: When does the LMP (or designee) have to sign the annual ISSP?

A: The LMP is required to sign the ISSP annually for as long as the individual is in continual services.

Q: Do alcohol and other drug (AOD) programs have to hire licensed health care practitioners to sign their ISSPs?

A: No. ISSR allows for A&D treatment staff to complete an AOD assessment and plan.


Intensive Community-based Treatment Services (ICTS)

Q: Since intensive community-based treatment services (ICTS) no longer are required to include family support, respite and behavior support plans, do children’s service coordination plans need to mention these services in the service agreement?

A: No.

Q: Why do ICT services no longer require a behavior support plan?

A: Stakeholders reported that this requirement was duplicative and added little value to plans created for the ICTS population.

Q: The rule still contains two references to behavior support plans. Can they be ignored?

A: Yes. The remaining references to behavior support plans will be removed when the ISSR is finalized in July 2013.


Other Questions (Related to ISSR)

Q: What types of professionals are considered to be licensed health care providers (LHPs)?

A: Any professional acting under the supervision of a state-operated licensing board is considered an LHP.

Q: What does periodic review of progress in the progress note mean?

A: Each outcome may have its own timeframe within which the services are expected to improve the individual’s symptom or condition. The periodic review is intended to examine if the prescribed services are having the intended effect. If the services are not having the intended effect, the clinician should re-examine the prescribed services to determine if another course of treatment would be more effective.

Q: Our electronic medical record specifically asks "did client or guardian participate in the development of this plan?" If we mark "yes," is that documentation adequate?

A: You should also include a service note stating how the individual participated.

Q: The webinar slideshow shows that certain parts of the rule were deleted, but they are still present in the revised rule as printed. Which is correct?   

A: Inconsistencies will be cleaned up during the permanent rule making process.

Q: Are the new rules consistent with Medicaid rules?

A: Yes

Q: When will the new rules be implemented?

A: The revised rules were effective February 11, 2013.

Q: Will these rules pass a Medicare audit?

A: OHA is not able to comment on Medicare requirements.

Q: Do we need to get a new consent at the beginning of a new episode of service?

A: Yes. All services provided must be supported by the informed consent of the individual or the reason consent could not be obtained.

Q: If we are going to provide a client with an additional service for which they will not be charged, do we have to have them sign a fee agreement?

A: No


Phase 2

Q: What is AMH’s plan for creating a licensing board for qualified mental health professionals (QMHPs)?

A: The ISSR workgroup is examining four specific questions in Phase 2:

  1. Which individuals need to be licensed/certified?
  2. Which programs need to be licensed/certified?
  3. What will the standards be for approval of individuals and programs?
  4. Who will license/certify individuals and programs?

One possibility the workgroup is exploring involves the licensing of qualified mental health professionals.

Q: What is the time line for Phase 2?

A: Phase 2 is scheduled to conclude at the end of April. However the topic likely will involve additional, ongoing work.

Q: How will the differences be resolved in provider certification requirements among AMH, OHP and private insurance?

A: The workgroup is exploring this issue as part of Phase 2.

Q: Why is the workgroup considering the redesign of process for licensing or certification of non-licensed providers?

A: There are many advantages to requiring that all providers be licensed or certified.   They include:

  1. Decreased administrative burden. As it is now, a licensed QMHP has to provide an additional signature on an ISSP developed by a non-licensed QMHP.
  2. Portability of credentials. This will make it easier for professional staff to move among different employers or work for multiple employers.
  3. Reduced red tape. It would allow patient-centered primary care homes and other programs that are not AMH-certified to employ QMHPs, QMHAs, and A&D counselors.
  4. Expanded opportunities. It could allow QMHPs to be on insurance panels for agencies that serve both publicly and privately covered individuals.
  5. Consistency. It would create consistent ethical codes and standards for all practitioners who deliver behavioral health services.

Q: Can a certifier from one of the tri-counties be added to the current workgroup?

A: The membership of the Phase 2 workgroup is firm. However, there will be ample opportunity for public comment on ISSR before it becomes a permanent rule. The rules advisory committee is still being created. The minutes from the workgroup meetings will be posted on AMH’s ISSR website for public review and comment.

Q: Will the workgroup examine the role of local mental health authorities during Phase 2?

A: Yes. During Phase 2 the workgroup is examining the roles and responsibilities of the coordinated care organizations, local mental health authorities and their community mental health programs, providers, and the Oregon Health Authority as they relate to Oregon’s future regulatory framework of the addictions and mental health system.