A. ED-Based Assessment/Linkage
Nine (9) of the Region 1 South EDs are within hospitals that have acute psychiatric inpatient units able to dispatch behavioral health specialists to the ED to perform crisis assessments, and to help make a linkage to an alternate care option. Six (6) hospitals do not have behavioral health specialists to attend to the person presenting with a psychiatric emergency.
This RFI seeks to augment the behavioral health assessment and linkage capacity at all 15 hospitals. For those not having internal behavioral health specialist, DHS will purchase a mobile outreach service from a community provider. The mobile assessment and linkage service will travel to the ED or co-locate there and perform these functions. For those nine (9) hospitals with behavioral health specialists, this RFI will seek to augment their work to provide the needed assessment and linkage function. Across all 15 EDs, the workers would conduct interviews, complete assessments and make recommendations for alternative care. Entry into services would be authorized by the ACARES Line (described below) and the worker would then proceed to make the necessary linkage to the service, including needed transportation (also described below).
Examples of appropriate "augmentation" at the nine (9) EDs with behavioral health could include:
- Adding QMHP level staff to perform crisis assessment on less than a 24/7/365 basis
- Enhancing QMHP level staff to reach 24/7/365 coverage in the ED
- Enhancing QMHP level staff to obtain double coverage on typically busy shifts or days of the week
- The addition of face-to-face Psychiatry/APN for rapid assessment, consultation, and/or the immediate initiation of active treatment (including psychotropic medications)
With such enhancements, the ED could assume broader authority and responsibility for recommending the appropriate level of service in the Region 1 South Crisis Care Network, working in concert with the ACARES provider. Providers filling this system need will need to project the staff time needed to respond on a 24/7/365 basis to one or more of the EDs in Region 1 South. Please refer to the above charts to gauge the possible volume and flow of referrals from the various EDs in the area. During the ACCT Committee process, stakeholders likened this function to that already done for children and adolescents in the current screening, assessment and linkage functions under the SASS Program, so this may be a useful consideration to a proposal under this RFI.
Qualified responders for ED-Based Assessment/Linkage are community hospitals duly licensed as a hospital within the State of Illinois with specifically designated psychiatric inpatient hospitalization program(s) for adults; fully certified as a Medicaid/Medicare provider; fully in compliance with the State of Illinois Mental Health Code and Confidentiality Act; fully accredited by the Joint Commission on Accreditation for Healthcare Organizations (TJC) or by Healthcare Facilities Accreditation Program (HFAP). Qualified community providers are those presently under contract with IDHS Division of Mental Health or the Division of Alcohol and Substance Abuse.
B. Community Hospital Inpatient Psychiatric Services (CHIPS)
CHIPS, is a contractual program between the state and local community hospitals for the purchase of inpatient psychiatric bed capacity for admissions of "indigent" persons with mental illnesses in acute crisis. Active treatment should be expected to resolve the crisis within a 6 day average length of stay. The program has active concurrent review, is reimbursed on an all-inclusive bed and professional fee-for-service rate, and expects immediate coordination of care efforts with the next level of care providers for services following discharge. IDHS/DMH would be payer of last resort after expedited applications for Medicaid are filed and have received final determination.
The initial basic contract that will be used to purchase this service can be found at:
FY12 Community Services Agreement Amendment 9/30/11 (pdf)
This contract will be supplemented by an addition that specifies the scope of service and payment. The CHIPS Scope of Services is attached at Appendix 6 titled Community Services Agreement Exhibit A Scope of Services.
The projected utilization of CHIPS for which DMH is proposing to receive for area hospitals is at Appendix 7 titled CHIPS Projections. DMH is wishing to contract with hospitals with existing inpatient Behavioral Health (BH) units for utilization numbers both from their ED but also to support portions of the other capacity from other area hospital EDs where no inpatient BH capacity exists. State hospital capacity will be available for safety net purposes. These numbers are for your consideration only. Contracts, with more specific targeted volumes will be let based upon submission of your proposals and subsequent negotiations with DMH.
Qualified responders for CHIPS services are community hospitals duly licensed as a hospital within the State of Illinois with specifically designated psychiatric inpatient hospitalization program(s) for adults; be fully certified as a Medicaid/ Medicare provider; fully in compliance with the State of Illinois Mental Health Code and Confidentiality Act; fully accredited by the Joint Commission on Accreditation for Healthcare Organizations (TJC) or by Healthcare Facilities Accreditation Program (HFAP). Providers certified to provide behavioral Medicaid services and under contract with IDHS/DASA or IDHS/DMH would also qualify.
C. Brief Intervention Linkage Teams (BILT)
BILTs are a version of a Crisis Stabilization Unit 2. These units are based either within an ED or psychiatric unit as programs of 3-5 beds. These programs are for individuals who are in need of a safe, secure environment that is less restrictive than inpatient hospitalization. BILTs can be designed for both voluntary and involuntary individuals. The program is to provide immediate active treatment with the goal of stabilizing the individual and re-integrate him or her back into the community quickly. The typical length of stay in a BILT is expected to be 36-48 hours.
Multi-disciplinary teams of mental health professionals staff BILTs, and provide rapid psychiatric assessment, observation to assess suicidal intent and risk, medication, counseling, referrals, and linkage and coordination to the appropriate level of services to be received post-discharge.
In some situations a BILT may also serve as a site for 24-hour walk-in crisis services for urgent situations, providing:
- Screening and assessment
- Crisis stabilization (including medication)
- Brief treatment
- Rapid linking with services
The BILT provider would have broader authority and responsibility for recommending a next level of service. Authorization for next level services may be the purview of the Region 1 South ACARES provider, but it is anticipated that close collaboration would make this a seamless effort between the two providers. A program description of an ED-based crisis stabilization service that reflects the model envisioned for this RFI is included at Appendix 8 titled Advocate Illinois Masonic Emergency Department-Behavioral Health.
Qualified responders for BILT services are community hospitals duly licensed as a hospital within the State of Illinois with specifically designated psychiatric inpatient hospitalization program(s) for adults; be fully certified as a Medicaid/Medicare provider; fully in compliance with the State of Illinois Mental Health Code and Confidentiality Act; fully accredited by the Joint Commission on Accreditation for Healthcare Organizations (TJC) or by Healthcare Facilities Accreditation Program (HFAP).
D. Crisis Outreach
Crisis Intervention is defined as: Activities or services provided to a person who is experiencing a psychiatric crisis. The services are designed to interrupt a crisis, and include: assessment, brief supportive therapy or counseling and referral and linkage to appropriate community services to avoid more restrictive levels of treatment. The goal of crisis intervention is symptom reduction, stabilization and restoration to the previous level of functioning. (See Community Mental Health Services Service Definition and Reimbursement Guide, page 29, (http://www.hfs.illinois.gov/assets/cmhs.pdf)
The Crisis Outreach service envisioned for this RFI is a total function that not only provides the services as described above, but also insures that the person served receives direct support necessary until a firm linkage to another service is in place or the crisis has been resolved. Service may need to be provided during a transitional period to facilitate the timely and rapid discharge from the Emergency Department once the next level of care is identified. Also, the service should provide access to other critical supports such as client transitional subsidies, options for temporary housing, transportation, Living Rooms, drop-in centers, etc. The crisis service may also be combined with the ED-base assessment/linkage described above.
In responding to this RFI providers should detail how they propose to establish a system to efficiently and effectively respond to referrals from one or more of the EDs in Region 1 South as part of Phase I of the Region 1 South Crisis Care System. However, the RFI response should also reflect how the provider's crisis response system may evolve to more flexibly respond to mental health crisis in other settings in the future, such as the development of a mobile crisis team.
The crisis outreach service may act as the primary mental health provider until it is appropriate to transition the individual into mainstream services. Qualified responders for crisis outreach would be providers certified to provide behavioral Medicaid services and under contract with IDHS/DASA or IDHS/DMH would also qualify.
E. DMH Crisis Residential
This level of residential care provides brief periods of care to consumers within a residential site when they are experiencing a psychiatric crisis to assist them to return to and maintain housing or residential stability in the community, continue with their recovery, and increase self-sufficiency and independence 3. This service includes 24 hour seven days per week access to crisis beds and residential support activities designed to provide short-term continuous supervision, crisis interventions, assessment and treatment. These services are to be delivered in a provider controlled facility with 24 hour crisis beds that are a part of or linked to Crisis Intervention Services.
The intense, rapid response service is highly focused on assessment, diagnosis, therapeutic intervention and stabilization of the presenting psychiatric crisis. Responses to this RFI may expand existing crisis residential programs or proposed the creation of new programs by provider agencies in order to meet the needs of individuals previously served by TPMHC. Qualified responders for crisis outreach would be providers certified to provide behavioral Medicaid services and under contract with IDHS/DASA or IDHS/DMH would also qualify.
F. DMH Enhanced Community Services
Under the current DMH Non-MRO service package, individuals are eligible for:
- Unlimited crisis intervention
- Mental health assessment (4 hours)
- Treatment plan development , review and modification (2 hours)
- Various types case management (5 hours)
- LOCUS case management (1.5 hours)
- Psychotropic medication administration (3 hours)
- Psychotropic medication monitoring (2 hours)
- Psychotropic medication training-individual (2 hours)
- Oral interpretation and sign language (25 hours)
The table describing covered services is attached at Appendix 9 titled NonMedicaid Service Package per Fiscal Year.
Responses to this RFI should include proposals to enhance the above service package to address the need for psychiatry appointments; brief supportive counseling or therapy, or other Rule 132 services that could help to continue the stabilization process. Qualified responders for crisis outreach would be providers certified to provide behavioral Medicaid services and under contract with DMH.
F. DASA (ASAM) III.5 & III.7 Residential
Currently the DMH State Hospitals discharge about one quarter of all persons served with a primary diagnosis of substance use disorder. Participants in recent ACCT clinical focus groups reviewed a sample of such individuals to render an expert opinion on what may have effectively been used as an alternative to the SOH admission. DASA Level 3.5 Residential Rehabilitation Services is viewed as a solid alternative for people with an SUD presenting at a community ED.
Level III.7 is a structured inpatient program which is consistent with the American Society of Addictive Medicine Patient Placement criteria for treatment of Substance Use Disorders (ASAM PPC-2R 2001). This service site should provide clinical services via an interdisciplinary team which assesses and addresses the individual needs of a client. Services may be medical services, individual, group, family or personal activity/social skills services. The services are planned clinical services and program activities designed to stabilize acute symptoms and or non-medical or psychiatric symptoms. Activities may include medication assisted treatment, cognitive behavioral, psychosocial rehabilitation, and or other therapies which may be individual or group that address the individual's disorders, psychological development, individual recovery supports and stage of recovery.
Level III.5 Residential Rehabilitation is typically short term (21 day or less) residential care provided in a 24-hour structured, safe, stable and supervised recovery setting (i.e. halfway houses, recovery homes). Active services are scheduled for a minimum of 25 hours per week and may include individual/group/family therapy, medication management/ education, interpersonal and group living skills group. Programs currently in operation may need to be enhanced to allow a rapid transition of the person from a Region 1 South ED. New programs would need to be designed for this rapid transfer as well.
Enhancements to the Level III.5 & III.7 need to consider access to a psychiatrist for medication assessment and administration, and the ability to safely monitor medication. Qualifying providers are licensed community substance abuse service providers certified to provide behavioral Medicaid services and under contract with DHS/DASA.
G. DASA Enhanced Community Services
A full continuum of services should be available to the clients deflected from the emergency departments, crisis intervention units, or referral sources. Such key services and new resources for these individuals should be for individuals with a substance abuse disorders who are in need of:
- Outpatient Services: Access to existing/enhanced outpatient (individual and group, and family) from individual to intensive outpatient services should be made available for those individuals medically stabilized and residing within the community. Such services should be able to address issues of co-morbidity and the need for Services integration.
- Medications and Medication Assisted Treatment: Access to necessary medications for the treatment of both psychiatric and substance use disorders for a designated time period defined by the department should be available.
- Recovery Coaches/Mentors: These services should be made available for individuals who have repeated crisis engagements and/or difficulty with successfully accomplishing their addiction and or psychiatric recovery plans. These services should be available 24/7 to individuals in need and need to integrate with and as a part of all services being provided to the client.
Qualifying providers are licensed community substance abuse service providers certified to provide behavioral Medicaid services and under contract with DHS/DASA.
2 Adams, C.L. & El-Mallakh, R.S. (2009) Patient Outcome after Treatment in a Community-Based Crisis Stabilization Unit. The Journal of Behavioral Health Services and Research, 36, 396-399.
3 Drawn from the draft Residential Rule 140 currently under development.