521586 Amendment to Chapter 34 of Title 22-A (Mental Health) to provide certification and eligibility requirements for Community-Based Intervention Level IV - Functional Family Therapy.

DEPARTMENT OF MENTAL HEALTH

NOTICE OF EMERGENCY AND PROPOSED RULEMAKING

The Director of the Department of Mental Health (Department), pursuant to the authority set forth in sections 104 and 105 of the Department of Mental Health Establishment Amendment Act of 2001, effective December 18, 2001 (D.C. Law 14-56; D.C. Official Code §§ 7-1131.04 and 7-1131.05), hereby gives notice of the adoption on an emergency basis of amendments to Chapter 34, “Mental Health Rehabilitation Services Provider Certification Standards” of Subtitle A, Mental Health, of Title 22 of the District of Columbia Municipal Regulations (DCMR).

The purpose of these amendments is to make changes to the requirements for certification of specialty providers of community based intervention (CBI) services for children and youth. The amendments establish eligibility requirements for receipt of functional family therapy (FFT) or CBI Level IV. The amendments establish the authorization period for FFT and the required membership of the FFT team of qualified practitioners.

Issuance of these rules on an emergency basis is necessary to expand the availability of community-based recovery-oriented programs for mental health consumers in the District of Columbia. Promulgation of the rules is expected to allow Medicaid funding to assist in the provision of these services, without which fewer people could benefit. Emergency action is necessary for the immediate preservation of the health, welfare, and safety of children, youth, and adults with mental illness in need of mental health services.

The emergency rulemaking was adopted on September 17, 2010, and will become effective on September 17, 2010. The emergency rules will remain in effect for one hundred twenty (120) days or until January 15, 2011, unless superseded by publication of another rulemaking notice in the D.C. Register, whichever comes first.

The Director also gives notice of intent to take final rulemaking action to adopt the proposed rules in no less than thirty (30) days after the date of publication of this notice in the D.C. Register.

CHAPTER 34,” MENTAL HEALTH REHABILITATION SERVICES PROVIDER CERTIFICATION STANDARDS,” OF SUBTITLE A, MENTAL HEALTH, OF TITLE 22 is amended as follows:

Subsection 3410.20 is amended by deleting the row in the chart labeled “Community-Based Intervention” and replacing it with the following:

Community-Based Intervention (CBI)

Levels I , II, III and IV - Twenty-four (24) hours per day, seven (7) days per week

Consumers authorized and referred for all levels of CBI shall be admitted within forty-eight (48) hours of referral by a CSA.

A CBI Team member shall respond to a call from a family member or a significant other, either by telephone or face- to-face contact, within sixty (60) minutes of receiving the call.

All CBI providers shall develop a crisis intervention plan for each consumer receiving CBI.

Level IV providers shall develop a crisis intervention plan for after-hours response which shall include the Mobile Crisis Response Team.

Subsection 3411.10 is amended to read as follows:

3411.10 Each CSA shall enter into an affiliation agreement with its sub-providers and all specialty providers that specifies the responsibilities of the parties, except for sub-providers and specialty providers providing ACT or CBI services. No affiliation agreement is needed for the provision of ACT or CBI services.

Subsection 3412.4 is amended to read as follows:

3412.4 Except for the provision of ACT or CBI services, specialty providers shall provide one (1) or more of the specialty services only through a referral arrangement with a CSA which is documented in an affiliation agreement. An affiliation agreement is not necessary for the provision of ACT or CBI services.

Subsection 3412.6 is amended to read as follows:

3412.6 Each sub-provider and specialty provider shall satisfy the following minimum staffing requirements:

(a) A Chief Executive Officer or Program Director with professional qualifications and experience who shall meet requirements as established by the MHRS provider’s governing authority and is responsible for day-to-day management of the MHRS provider;

(b) A sub-provider or specialty provider who provides rehabilitation/day services must also have a Consulting Psychiatrist who is a board-eligible psychiatrist and advises the sub-provider or specialty provider on the quality of medical and psychiatric care provided;

(c) A Clinical Director who is a qualified practitioner with overall responsibility for oversight of the clinical program of the sub-provider or specialty provider;

(d) Each sub-provider who provides either Diagnostic/Assessment or Medication/Somatic Treatment shall demonstrate adequate oversight of quality of medical and psychiatric care by employing or contracting with a Medical Director or arranging for the Medical Director for the consumer's CSA to provide such oversight; and

(e) The required staff listed in this subsection shall be either employees of the sub-provider or specialty provider or under contract to the sub-provider or specialty provider for an amount of time sufficient to carry out the duties assigned.

Section 3422 is deleted in its entirety and replaced with the following:

3422 COMMUNITY-BASED INTERVENTION

3422.1 CBI services are time-limited, intensive, mental health services delivered to children and youth ages six (6) through twenty-one (21). CBI services are intended to prevent the utilization of an out-of-home therapeutic resource or a detention of the consumer. CBI services may be provided at the time a child or youth is identified for a service, particularly to meet an urgent or emergent need during his or her course of treatment.

3422.2 In order to be eligible for CBI services, a consumer shall have:

(a) Insufficient or severely limited individual or family resources or skills to cope with an immediate crisis; and

(b) Either individual or family issues, or a combination of individual and family issues, that are unmanageable and require intensive coordinated clinical and positive behavioral interventions.

3422.3 There shall be four (4) levels of CBI services available to children and youth. A provider may be certified to offer one (1) or more level(s) of CBI services. The four (4) levels of CBI services are:

(a) CBI Level I, delivered using the Multisystemic Therapy (MST) treatment model adopted by DMH;

(b) CBI Level II, delivered using the Intensive Home and Community-Based Services (IHCBS) model adopted by DMH;

(d) CBI Level IV, delivered using the Functional Family Therapy (FFT) model adopted by DMH.

3422.4 All levels of CBI services shall include the services described in subsection 3422.7, as medically necessary and clinically appropriate for the consumer.

3422.5 The CBI provider shall be responsible for coordinating the treatment planning process for all consumers authorized to receive CBI for the duration of CBI services. CBI services shall be delivered primarily in natural settings and shall include in-home services.

3422.6 The basic goals of all levels of CBI services are to:

(a) Defuse the consumer’s current situation to reduce the likelihood of a recurrence, which, if not addressed, could result in the use of more intensive therapeutic interventions;

(b) Coordinate access to covered mental health services and other covered Medicaid services;

(c) Provide mental health services and support interventions for consumers that develop and improve consumer and family interaction and improve the ability of parents, legal guardians, or caregivers to care for the consumer; and

(d) Transition the consumer to an appropriate level of care following the end of CBI treatment services.

3422.7 All levels of CBI services shall include the following services, as medically necessary and clinically appropriate for the consumer:

(a) Immediate crisis response for enrolled consumers;

(b) Stabilization services to:

(1) Reduce family conflict;

(2) Stabilize the family unit;

(3) Maintain the consumer in the home environment;

(4) Increase family support; and

(5) Monitor the consumer’s medication compliance with prescribed psychiatric medications;

(1) Identify risk factors that may endanger either the consumer or the consumer’s family; and

(2) Assess the strengths of the consumer and the consumer’s family;

(d) Individual and family support interventions that develop and improve the ability of parents, legal guardians, or significant others to care for the consumer’s behavioral and emotional disturbance(s);

(e) Skills training related to:

(1) Consumer self-help;

(2) Parenting techniques to help the consumer’s family develop skills for managing the consumer’s emotional disturbance;

(3) Problem solving;

(4) Behavior management;

(5) Communication techniques, including the facilitation of communication and consistency of communication for both the consumer and the consumer’s family; and

(6) Medication management, monitoring, and follow-up for family members and other caregivers; and

(f) Coordination and linkage with other covered MHRS and supports and other covered Medicaid services in order to prevent the utilization of more restrictive residential treatment, including one (1) or more of the following activities:

(1) Referral of consumers to other MHRS providers;

(2) Assisting consumers in transition to less intensive or more intensive MHRS;

(3) Referral of consumers to providers of other Medicaid covered services (for example, physicians); or

(4) Supporting and consulting with the consumer’s family or support system, which is directed exclusively to the well-being and benefit of the consumer.

3422.8 CBI Level I services are intended for children and youth who are experiencing serious emotional disturbance with either of the following:

(a) A documented behavioral concern with externalizing (aggressive or violent) behaviors; or

(b) A history of chronic juvenile offenses that has or may result in involvement with the juvenile justice system.

3422.9 CBI Level I services shall not be authorized for:

(a) Children or youth who require the safety of a hospital or other secure setting;

(b) Children or youth in independent living programs; or

3422.10 Eligible consumers of CBI Level I services shall have a permanent caregiver who is willing to participate with service providers for the duration of CBI Level I treatment services and be:

(a) At imminent risk for out-of-home placement within thirty (30) days; or

(b) Currently in out-of-home placement due to the consumer’s disruptive behavior, with permanent placement expected to occur within thirty (30) days.

3422.11 CBI Level I Service providers shall obtain prior authorization of CBI Level I services from DMH for a period not to exceed six (6) months.

3422.12 Re-admission to CBI Level I services, after the six (6)-month period, may be considered for prior authorization by DMH in accordance with medical necessity requirements specified by DMH.

3422.13 CBI Level I services shall be delivered in accordance with the Multisystemic Treatment (MST) Model.

3422.14 Eligible consumers of CBI Level II services shall have any one (1) or combination of the following:

(a) A history of involvement with the Child and Family Services Agency (CFSA) or the Department of Youth Rehabilitation Services (DYRS);

(b) A history of negative involvement with schools for behavioral-related issues; or

(c) A history of either chronic or recurrent episodes of negative behavior that have or may result in out-of-home placement.

3422.15 CBI Level II services shall not be authorized for children or youth who require the safety of a hospital or other secure setting.

3422.16 CBI Level II service providers shall obtain prior authorization of CBI Level II services from DMH for a period not to exceed six (6) months.

3422.17 Readmission to CBI Level II services, after the six (6)-month period, may be considered for prior authorization by DMH in accordance with medical necessity requirements specified by DMH.

3422.18 CBI Level II services shall be delivered in accordance with the Intensive Home and Community-Based Services (IHCBS) model as adopted by DMH.

3422.19 A consumer shall be eligible for CBI Level III services if the consumer:

(a) Has situational behavioral problems that require short-term, intensive treatment;

(b) Is currently dealing with stressor situations such as trauma or violence and requires development of coping and management skills;

(c) Recently experienced out-of-home placement and requires development of communication and coping skills to manage the placement change;

(d) Is undergoing transition from adolescence to adulthood and requires skills and supports to successfully manage the transition;

(e) Was recently discharged from an inpatient setting such as acute hospitalization or psychiatric residential treatment facility; or

(f) Is an adult parent or caregiver with a clinically significant mental health concern and the parent or caregiver will be parenting a child or youth returning from a residential treatment center within the next ninety (90) days.

3422.20 CBI Level III services shall not be authorized for children or youth who require the safety of a hospital or other secure setting.

3422.21 CBI Level III service providers shall obtain prior authorization for CBI Level III services from DMH for a period not to exceed ninety (90) days.

3422.22 Readmission to CBI Level III services, after the ninety (90)-day period, may be considered for prior authorization by DMH in accordance with medical necessity requirements specified by DMH.

3422.23 CBI Level III services shall be delivered in accordance with the IHCBS model as adopted by DMH.

3422.24 Eligible consumers of CBI Level IV services shall:

(a) Be between the ages of ten (10) and eighteen (18); and

(b) Have a documented history of moderate to serious behavioral problems which impair functioning in at least one (1) area (for example school or home), or

(c) Exhibit significant externalizing behavior which impairs functioning in at least one (1) area (for example school or home); or

(d) Be at risk of a disruption in placement; and

(e) Be:

(1) Willing to participate with service providers for the duration of CBI Level IV treatment services; or

(2) Involved with a caregiver who is willing to participate with service providers for the duration of CBI Level IV treatment services.

3422.25 CBI Level IV services shall not be authorized for:

(a) Children or youth who require the safety of a hospital or other secure setting;

(b) Children or youth in congregate living programs; or

3422.26 CBI Level IV Service providers shall obtain prior authorization of CBI Level IV services from DMH for a period not to exceed six (6) months.

3422.27 Readmission to CBI Level IV services, after the six (6)-month period, may be considered for prior authorization by DMH in accordance with medical necessity requirements specified by DMH.

3422.28 A maximum of twenty-four (24) additional units of CBI Level IV services may be delivered at the discretion of the provider, in consultation with the consumer and the consumer’s caregiver without an additional authorization, within twelve (12) months of the close of the initial six (6) month authorization period.

3422.29 CBI Level IV services shall be delivered in accordance with the FFT model adopted by DMH.

3422.30 Discharge from all levels of CBI services shall occur when the consumer’s level of functioning has improved with respect to the goals outlined in the IPC and ISSP or the consumer no longer benefits from CBI services. Discharge decisions shall be based on one (1) or a combination of the following:

(a) The consumer is performing reasonably well in relation to goals contained in the IPC and ISSP and discharge to a lower level of care is indicated (for example, the consumer is not exhibiting risky behaviors or family functioning has improved);

(b) The consumer or the consumer’s family or caregiver has developed the skills and resources needed to step down to a less intensive service;

(d) A family member or caregiver requests discharge and the consumer is not imminently dangerous to self or others;

(e) The consumer requires a higher level of care (for example, inpatient hospitalization or psychiatric residential treatment facility); or

(f) The consumer does not reside in the District and:

(1) Is not eligible to participate in the District’s Medicaid program;

(2) Is not within the physical or legal custody of Child and Family Services Agency (CFSA); or

(3) Is not within the physical or legal custody of the Department of Youth Rehabilitation Services (DYRS).

3422.31 Eligible providers of CBI Level I services shall:

(a) Meet the specialty service provider requirements in § 3412;

(b) Be licensed MST providers in good standing and utilize the MST treatment model;

(c) Have the capacity to provide or arrange for the non-Medicaid reimbursed wraparound services required by eligible consumers;

(1) Have the capacity to deliver CBI Level I services to four (4) to six (6) consumers for each full-time team member; and

(2) Be available to consumers twenty-four (24) hours per day, seven (7) days per week.

3422.32 Eligible providers of CBI Level II services shall:

(a) Meet the specialty service provider requirements in § 3412;

(b) Utilize the IHCBS treatment model adopted by DMH to deliver CBI Level II services;

(1) Have the capacity to provide or arrange for the non-Medicaid reimbursed wraparound services required by eligible consumers;

(2) Have the capacity to deliver CBI Level II services to at least four (4) to six (6) consumers for each full-time team member; and

(3) Be available to consumers twenty-four (24) hours per day, seven (7) days per week.

3422.33 Eligible providers of CBI Level III services shall:

(a) Meet the specialty service provider requirements in § 3412;

(b) Utilize the IHCBS treatment model adopted by DMH to deliver CBI Level III services;

(d) Have the capacity to provide or arrange for the non-Medicaid reimbursed wraparound services required by eligible consumers;

(e) Have the capacity to deliver CBI Level III services to at least four (4) to six (6) consumers for each full-time team member; and

(f) Be available to consumers twenty-four (24) hours per day, seven (7) days per week.

3422.34 Eligible providers of CBI Level IV services shall:

(a) Meet the specialty service provider requirements in § 3412;

(b) Have current site certification as an FFT provider and utilize the FFT treatment model to deliver CBI Level IV services;

(d) Comply with the CBI Level IV training and site certification requirements specified by DMH;

(e) Have the capacity to provide or arrange for the non-Medicaid reimbursed wraparound services required by eligible consumers;

(f) Have the capacity to deliver CBI Level IV services to at least ten (10) to twelve (12) consumers for each full-time therapist; and

(g) Be available to work a flexible schedule based on the needs of the consumer and the family or caregiver.

3422.35 Providers of CBI services shall meet the staffing requirements applicable to the level of services offered in order to render CBI Level I, Level II, Level III or Level IV services.

3422.36 Providers of all levels of CBI services shall:

(a) Individually design CBI services for each consumer and family to minimize intrusion and maximize independence;

(b) Provide more intensive services at the beginning of treatment and decrease the intensity of treatment over time as the strengths and coping skills of the consumer and family develop;

(d) Maintain appropriate back-up coverage for team member absences and facilitate substitution of team members as necessary;

(e) Conduct face-to-face transition planning with consumers and families no later than thirty (30) days prior to the anticipated discharge date, including meetings with providers of more intensive or less intensive services;

(f) Conduct continuity of care planning with consumers and families prior to discharge from any level of CBI services, including facilitating follow-up mental health appointments and providing telephonic support until follow-up mental health services occur;

(g) Provide all of the components of treatment specified in §3422.7, as appropriate, based on each consumer’s needs;

(h) Provide CBI services with a family-focus;

(i) Assist the consumer and his or her family with the development of mental health relapse prevention strategies and plans, if none exist;

(j) Assist the consumer and his or her family with the development of a safety plan to address risk factors identified during the environmental assessment;

(k) Have policies and procedures included in its Service Specific Policies that address the provision of CBI (CBI Organizational Plan) which include the following:

(1) A description of the particular treatment models utilized, types of intervention practiced, and typical daily curriculum and schedule;

(2) A description of the staffing pattern and how staff are deployed to ensure that the required staff‑to‑consumer ratios are maintained, including how unplanned staff absences and illnesses are accommodated; and

(3) A description of how the ISSP is modified or adjusted to meet the needs specified in each consumer’s IPC;

(4) A requirement to directly conduct or arrange for the provision of Diagnostic/Assessment services within thirty (30) days before or after the initiation of CBI services through either an agreement with a CSA or a CSA’s affiliated sub-provider. DMH may approve alternative sources to serve as the diagnostic assessment instrument if similar assessments have been conducted within the past twelve (12) months of an individual’s referral to CBI services; and

(5) A requirement to collect and submit clinical outcome data using the process, timeline and tools specified or approved by DMH.

3422.37 Each CBI Level I team shall include:

(a) A full-time clinical supervisor;

(b) A full-time team leader; and

3422.38 The CBI Level I team clinical supervisor shall be a Master’s level qualified practitioner experienced in providing individual, group, marital or family counseling or psychotherapy in accordance with applicable District laws and regulations, with a minimum of two (2) years of post-graduate experience working with behaviorally challenged youth and their families in community-based settings.

3422.39 The CBI Level I team leader shall be a Master’s level clinician with a minimum of one (1) year of post-graduate experience working with behaviorally challenged youth and their families in community-based settings.

3422.40 The CBI Level I team clinicians shall be either Master’s level clinicians or Bachelor’s level clinicians with a minimum of one (1) year of experience working with behaviorally challenged youth and their families in community-based settings.

3422.41 Each CBI Level II team shall include:

(a) A full-time clinical supervisor; and

(b) Four (4) to six (6) clinicians.

3422.42 The CBI Level II team clinical supervisor shall be a Master’s level qualified practitioner experienced in providing individual, group, marital or family counseling or psychotherapy in accordance with applicable District laws and regulations, with a minimum of two (2) years of post-graduate experience working with behaviorally challenged youth and their families in community-based settings.

3422.43 The CBI Level II team clinicians shall be either Master’s level clinicians or Bachelor’s level clinicians with a minimum of one (1) year of experience working with behaviorally challenged youth and their families in community-based settings.

3422.44 Each CBI Level III team shall include:

(a) A full-time clinical supervisor; and

(b) Four (4) to six (6) clinicians.

3422.45 The CBI Level III team clinical supervisor shall be a Master’s level qualified practitioner experienced in providing individual, group, marital or family counseling or psychotherapy in accordance with applicable District laws and regulations, with a minimum of two (2) years post-graduate experience working with behaviorally challenged youth and their families in community-based settings.

3422. 46 The CBI Level III team clinicians shall be either Master’s level qualified practitioners or Bachelor’s level clinicians with a minimum of two (2) years of experience working with behaviorally challenged youth and their families in community-based settings.

3422.47 Each CBI Level IV team shall include:

(a) A full-time clinical supervisor who has satisfied the FFT requirements for a clinical supervisor; and

(b) Three (3) to eight (8) fulltime equivalent clinicians who have satisfied the FFT requirements for a therapist.

3422.48 The CBI Level IV team clinical supervisor shall be a Master’s level qualified practitioner experienced in providing individual, group, marital or family counseling or psychotherapy in accordance with applicable District laws and regulations, with a minimum of two (2) years of post-graduate experience working with behaviorally challenged youth and their families in community-based settings who has satisfied the FFT requirements for a clinical supervisor.

3422.49 The CBI Level IV clinicians shall be either Master’s level clinicians or Bachelor’s level clinicians with a minimum of one (1) year of experience working with behaviorally challenged youth and their families in community-based settings, and shall have satisfied the FFT requirements for FFT therapists.

3422.50 Providers of all levels of CBI services shall ensure the availability and provision of alcohol and other drug addiction treatment services as well as services to facilitate consumers’ transition from adolescence to adulthood, as medically necessary for consumers.

3422.51 Prior authorization from DMH is required for enrollment in all levels of CBI services.

3422.52 CBI shall not be billed on the same day as Rehabilitation/Day Services, Intensive Day Treatment or ACT.

3422.53 CBI shall not be billed on the same day as Counseling without the prior approval of DMH.

3422.54 CBI shall not be billed on the same day as Community Support unless the Community Support services are provided within thirty (30) days prior to the consumer’s discharge from CBI.

3422.55 CBI shall be provided in:

(a) MHRS provider service sites; or

(b) Natural settings, including the consumer’s home or other community setting.

3422.56 Qualified practitioners of CBI are:

(a) Psychiatrists;

(b) Psychologists;

(d) Advance Practice Registered Nurses (APRNs);

(e) Registered Nurses (RNs);

(f) Licensed Professional Counselors (LPCs);

(g) Licensed Independent Social Workers (LISWs); and

(h) Addiction counselors.

3422.57 All credentialed staff, including recovery specialists, shall be authorized to provide CBI under the supervision of a qualified practitioner as set forth in §3413.3.

3422.58 CBI services shall not exceed thirty-two (32) units in a twenty-four (24) hour period, without prior authorization from DMH. DMH may conduct clinical record reviews to verify the medical necessity of services provided.

Section 3499.1 is amended as follows:

The following definitions are added in alphabetical order within the existing list of definitions:

“Functional Family Therapy” or “FFT” – research-based prevention and intervention program for at-risk adolescents and their families provided by a team of trained therapists by a certified CBI Level IV provider with FFT site certification.

“Mobile Crisis Response Team” – a team of mental health clinicians who provide face-to-face and telephone support to children and families in crisis.

All persons desiring to comment on the subject matter of this proposed rulemaking should file comments in writing no later than thirty (30) days after the date of publication of this notice in the D.C. Register. Comments should be filed with Suzanne Fenzel, Department of Mental Health, 64 New York Avenue, N.E., Fourth Floor, Washington, D.C. 20002 or Suzanne.Fenzel@dc.gov. Additional copies of these rules are available from the Office of the General Counsel, Department of Mental Health.

Visit the Official Version

Document Information

Rules:: 22-A3410
22-A3411
22-A3412
22-A3422
22-A3499