AND 3. One of the following:

• Continued difficulty participating in traditional clinic-based services or a community setting at a less intensive level of service/supports;

• Substandard housing, homeless, or at imminent risk of becoming homeless due to functional impairments associated with behavioral health issues;

• Living arrangement through a Georgia Housing Voucher and needs ongoing support to maintain stable housing; and

• Experienced recent life changing event (Examples include Death of Significant Other or close family member, Change in marital status, Involvement with criminal justice system, Serious Illness or injury of self or close family member, financial issues including loss of job, disability check, etc.) and needs intensive support to prevent the utilization of crisis level services.

Discharge Criteria

1. There has been a planned reduction of units of service delivered and related evidence of the individual sustaining functioning through that reduction plan; and 2. Individual has established recovery support networks to assist in maintenance of recovery (such as peer supports, AA, NA, etc.); and

3. Individual has demonstrated some ownership and engagement with her/his own illness self-management as evidenced by:

a. navigating and self-managing necessary services;

b. maintaining personal hygiene;

c. meeting his/her own nutritional needs;

d. caring for personal business affairs;

e. obtaining or maintaining medical, legal, and housing services;

f. recognizing and avoiding common dangers or hazards to self and possessions;

g. performing daily living tasks;

h. obtaining or maintaining employment at a self-sustaining level or consistently performing homemaker roles (e.g., household meal preparation, washing clothes, budgeting, or childcare tasks and responsibilities); and

i. maintaining a safe living situation.

Service Exclusions

1. This service may not duplicate any discharge planning efforts which are part of the expectation for hospitals, ICF-MRs, Institutions for Mental Disease (IMDs), and Psychiatric Residential Treatment Facilities (PRTFs) for youth transition population.

2. This service is not available to any individual who receives a waiver service via the Department of Community Health. Payment for ICM Services under the plan shall not duplicate payments made to public agencies or private entities under other program authorities for this same purpose.

3. Individuals with a substance-related disorder are excluded from receiving this service unless there is clearly documented evidence of a co-occurring psychiatric

Intensive Case Management

diagnosis.

4. For individuals receiving this service, “Service Plan Development” utilization should be limited and supplanted with this service.

5. ACT, CST, and CM are Service Exclusions. Individuals may receive ICM and one of these services for a limited period of time to facilitate a smooth transition.

Clinical Exclusions

Individuals with the following conditions are excluded from admission unless there is clearly documented evidence of a psychiatric condition co-occurring with the diagnosis of:

• mental retardation; and/or

• autism; and/or

• organic mental disorder; and/or

• traumatic brain injury.

Required Components

1. Each provider must have policies and procedures related to referral including providing outreach to agencies who may serve the targeted population, including but not limited to psychiatric inpatient hospitals, Crisis Stabilization Units, jails, prisons, homeless shelters, etc..

2. The organization must have policies and procedures for protecting the safety of staff that engage in these community-based service delivery activities.

3. Maintain face-to-face contact with individuals receiving Intensive Case Management services, providing a supportive and practical environment that promotes recovery and maintain adherence to the desired performance outcomes that have been established for individuals receiving ICM services. It is expected that frequency of face-to-face contact is increased when clinically indicated in order to achieve the performance outcomes, and the intensity of service is reflected in the individual’s IRP.

4. A median of 4 face-to-face visits must be delivered on a monthly basis. Additional contacts may be either face-to-face or telephone collateral contact (denoted by the UK modifier) depending on the individual’s support needs.

5. 60% of total units must be face-to-face contacts with the individual.

6. At least 50% of all face-to-face service units must be delivered in non-clinic/community-based settings (i.e., any place that is convenient for the individual such as a FQHC, place of employment, community space) over the authorization period (these units are specific to single individual records and are not aggregate across an agency/program or multiple payers).

7. In the absence of monthly face-to-face contacts and if at least two unsuccessful attempts to make face-to-face contact have been tried and documented, the provider may bill for a maximum of 2 telephone contacts in that specified month (denoted by the UK modifier). This may occur for no more than 60 consecutive days.

8. After 8 unsuccessful attempts at making face to face contact with an individual, the ICM and members of the treatment/support team will re-evaluate the standing IRP and utilization of services.

9. ICM is expected to retain a high percentage of enrolled individuals in services with few drop-outs. In the event that an ICM has documented multiple attempts to locate and make contact with an individual and has demonstrated diligent search, after 60 days of unsuccessful attempts the individual may be discharged due to drop out.

10. Individuals for whom there is a written transition/discharge plan may receive a tapered benefit based upon individualized need as documented in that plan.

11. Team meetings must be held a minimum of once a week and time dedicated to discussion of support and service to individuals must be documented in the Treatment Team Meetings Log. Each individual must be discussed, even if briefly, at least one time monthly. ICM staff members are expected to attend Treatment Team Meetings.

Staffing Requirements

1. The following practitioners may provide ICM services:

• Practitioner Level 1: Physician/Psychiatrist (reimbursed at Level 4 rate)

• Practitioner Level 2: Psychologist, APRN, PA (reimbursed at Level 4 rate)

• Practitioner Level 3: LCSW, LPC, LMFT, RN (reimbursed at Level 4 rate)

• Practitioner Level 4: LMSW; LAPC; LAMFT; Psychologist/LCSW/LPC/LMFT’s supervisee/trainee with at least a Bachelor’s degree in one of the helping professions such as social work, community counseling, counseling, psychology, or criminology, functioning within the scope of the practice acts of the state;

Intensive Case Management

MAC, CAC-II, CADC, CCADC, GCADC (II, III); CPS, PP, CPRP, CAC-I or Addiction Counselor Trainees with at least a Bachelor’s degree in one of the helping professions such as social work, community counseling, counseling, psychology, or criminology

• Practitioner Level 5: CPS; PP; CPRP; or, when an individual served is co-occurring diagnosed with a mental illness and addiction issue CAC-I, RADT (I, II, or III), Addiction Counselor Trainees with high school diploma/equivalent under supervision of one of the licensed/credentialed professionals above.

2. Each ICM provider shall have a minimum of 11 staff members which must include 1 full-time licensed supervisor and 10 full-time case managers. When provided by one of the practitioners cited below, must be under the documented supervision (organizational charts, supervisory notation, etc.) of one of the independently licensed/credentialed professionals above:

• Certified Peer Specialists

• Paraprofessional staff

• Certified Psychiatric Rehabilitation Professional

• Certified Addiction Counselor-I

• Registered Alcohol and Drug Technician (I,II, or III)k

• Addiction Counselor Trainee

3. Oversight of an intensive case manager is provided by an independently licensed practitioner.

4. Staff to consumer ratio for ICM services shall be a maximum caseload of 1:20 quarterly in rural areas and 1:30 in urban areas. Minimum caseloads in rural areas are 1:15 and 1:25 in urban areas. These ratios reflect a maximum team capacity of 200 in rural areas and 300 in urban areas. Urban counties are delineated in the annual Georgia County Guide with the term “Metropolitan County”.

Clinical Operations

1. ICM may include (with the consent of the Adult) coordination with family and significant others and with other systems/supports (e.g., work, religious entities, corrections, aging agencies, etc.) when appropriate for treatment and recovery needs.

2. ICM providers must have the ability to deliver services in various environments, such as homes, homeless shelters, or street locations. The provider should keep in mind that individuals may prefer to meet staff at a community location other than their homes or other conspicuous locations (e.g. their place of employment), especially if staff drive a vehicle that is clearly marked as a state or agency vehicle, or if staff must identify themselves and their purpose to gain access to the individual in a way that may potentially embarrass the individual or breech the individual’s privacy/confidentiality. Staff should be sensitive to and respectful of individuals’ privacy/confidentiality rights and preferences in this regard to the greatest extent possible (e.g. if staff must meet with an individual during their work time, if the individual wishes, mutually agree upon a meeting place nearby that is the least conspicuous from the individual’s point of view).

3. ICM must incorporate assertive engagement techniques to identify, locate, engage, and retain the most difficult to engage enrolled individuals who cycle in and out of intensive services. ICM must demonstrate the implementation of well thought out engagement strategies to minimize discharges due to drop out including the use of street and shelter outreach approaches and collateral contacts with family, friends, probation or parole officers.

4. ICM is expected to assertively participate in transitional planning, coordinating, and accessing services and resources when an enrolled individual is being discharged from a psychiatric hospital; released from jail; or experiencing an episode of homelessness. An ICM provider that is also a Tier 1 or Tier 2 Provider may use

Community Transition Planning to establish a connection or reconnection to the individual while in a state operated hospital, crisis stabilization unit, jail/prison, or other community psychiatric hospital, and participate in discharge planning meetings. Because of the complex needs of the target population, ICM may only be delivered by a Tier 1 or Tier 2 Provider. It is expected that any individual receiving ICM services will be connected to a Tier 1 or Tier 2 Provider or other service provider where they receive ongoing physician assessment and treatment as well as other recovery-supporting services. There shall be documentation during each Authorization Period that demonstrates ICM collaboration efforts with the individual’s physician and other recovery supporting services.

5. The organization must have policies that govern the provision of services in natural settings and can document that the organization respects individuals’ rights to privacy and confidentiality when services are provided in these settings.

6. The organization has established procedures/protocols for handling emergency and crisis situations:

a. The organization jointly develops the crisis plan in partnership with the individual. The organization is engaged with the individual to ensure that the plan is complete, current, adequate, and communicated to all appropriate parties.

Intensive Case Management

b. There is evaluation of the adequacy of the individual’s crisis plan and its implementation at periodic intervals including post-crisis events.

o while respecting the individual’s crisis plan and identified points of first response, the policies should articulate the role of the Tier 1 or Tier 2 provider agency to be the primary responsible provider for providing crisis supports and intervention as clinically necessary

o describe methods for supporting individuals as they transition to and from psychiatric hospitalization/crisis stabilization.

7. The organization must have an ICM Organizational Plan that addresses the following:

a. description of the role of ICM during a crisis in partnership with the individual, and Tier 1 or Tier 2 provider or other clinical home service provider where the individual receives ongoing physician assessment and treatment as well as other recovery supporting services.

b. description of the staffing pattern and how staff are deployed to assure that the required staff-to-individual ratios are maintained, including how unplanned staff absences, illnesses, or emergencies are accommodated, case mix, access, etc.

c. description of the hours of operations as related to access and availability to the individuals served;

d. description of how the IRP plan constructed, modified and/or adjusted to meet the needs of the individual and to facilitate broad natural and formal support participation; and

e. description of how ICM agencies engage with other agencies who may serve the target population.

Service

Accessibility There must be documented evidence that service hours of operation include evening, weekend, and holiday hours.

Reporting and Billing Requirements

When a billable collateral contact is provided, the UK reporting modifier shall be utilized. A collateral contact is classified as any contact that is not face-to-face with the individual.