Exhibit A - Scope of Services

The Community Hospitalization Inpatient Psychiatric Services (CHIPS) program is intended to serve those persons with serious mental illness (SMI) and predominately those with serious and persistent mental illness (SPMI) as defined by IDHS (available at http://www.dhs.state.il.us/page.aspx?item=32632) who exhibit acute behaviors or symptoms requiring the services of an immediate inpatient setting. To maximize State resources, funds used to reimburse these services are used only after all other appropriate sources of reimbursement have been exhausted, and only for those persons in specific financial need as defined as under 200% Federal poverty level (FPL) as found at 2012 HHS Poverty Guidelines - One Version of the [U.S.] Federal Poverty Measure (http://aspe.hhs.gov/poverty/12poverty.shtml).

  1. Inpatient psychiatric hospital services for the treatment of an adult (18 years of age and older) may only be provided as medically necessary for active treatment and which can reasonably be expected to improve the patient's condition. To be eligible for reimbursement by the CHIPS program, the guidelines in Attachment 1 must be followed.
  2. The Provider shall cooperate with the IIDHS/DMH Region Utilization Review process, with treatment limited to continuous inpatient hospitalization, as authorized, per episode. The concurrent approval by the IIDHS/DMH Region Office is needed to qualify for consideration for payment under this CHIPS program. Requests for extensions of hospitalization must include the clinical rationale from the Provider.
  3. The Provider will provide all of the following services:
    1. Inpatient Psychiatric Services, which includes:
      1. Daily Room and Board;
      2. Admitting physical examination and medical history;
      3. Routine assessments including nursing, social service and functional assessments;
      4. Routine laboratory and diagnostic evaluations;
      5. Individual treatment plan development and implementation;
      6. All inpatient therapies and services, including pharmaceutical treatments, under the direction of the attending psychiatrist or hospitalist resulting from the initial comprehensive psychiatric evaluation, diagnosis, and daily assessments;
      7. All inpatient therapies, programs and services that are part of the ongoing schedule of the provider's Psychiatric Services Inpatient Unit.
      8. A staffing within 72 hours of admission with participation of a psychiatric unit representative, a designated IIDHS/DMH funded community mental health service provider representative, and the consumer and legal guardian as indicated (and family, if authorized);
      9. Documented discharge planning with participation of a psychiatric unit representative and a designated IIDHS/DMH funded community mental health service provider representative, and the consumer and legal guardian as indicated (and family, if desired).
    2. Attending Psychiatric Physician Services, which includes the provision of medical coverage by psychiatrists credentialed and privileged by the Provider and minimally providing:
      1. Completion of an admission psychiatric evaluation within 24 hours of admission;
      2. Direction of inpatient therapies and services, including pharmaceutical treatments;
      3. Daily care with the patient, consisting of at least six face-to-face visits per seven day period is minimally expected;
      4. Completion of all documentation requirements for medical records in accordance to the Provider's policies, procedures or Medical Staff By-Laws.
    3. Exceptional Psychiatric-related Medical Services: Upon written request and prior approval, the IIDHS/DMH Region Office may also authorize payment at currently established IDHFS rates for those exceptional psychiatrically-related medical services such as: non-routine medically prescribed evaluations, assessments and treatments, physician or professional consultative services necessary to diagnose or treat the consumer's presenting psychiatric symptoms. Services may be performed on an emergency basis, but approval by the IIDHS/DMH Region Office is still required for consideration of payment for such services.
    4. D. Transportation: The hospital provider may request reimbursement for the safe and secure transport of a patient (consumer) to court, related to any involuntary admission or involuntary treatment or medication requests. IIDHS/DMH, at its sole discretion, may provide such transport through its contracted vendor.
    5. E. Psychiatrist Court Appearance: Should it be required that the attending psychiatrist appear in court regarding an Involuntary Admission or Involuntary Treatment or Medication request, the psychiatrist may request reimbursement for that court appearance time at the rate of $75.00 per hour or part thereof.
  4. Immediately following admission, the Provider, in collaboration with the designated IIDHS/DMH-funded community mental health service provider, must begin the process of identifying and planning for the appropriate aftercare resources for continuity of care.
  5. The Provider must ensure that:
    1. A complete application for Medicaid, AllKids or all other eligibility programs administered by the IDHS or IDHFS has been filed for consumer(s) under this program, and
    2. It has received documentation that the application for eligibility has been denied under categories Type Action Reason (TAR) 17 (applicant determined not disabled by the Social Security Administration (SSA), TAR 18, applicant determined not disabled by IDHS Client Assessment Unit (CAU); and/or for specific cases as identified prior to discharge, the IIDHS/DMH Region Office may also consider TAR Category 07 (applicant not an Illinois resident) or TAR 05 (applicant does not meet citizen Immigration and Naturalization Service (INS) requirements) as a qualifying denial.
    3. A complete application completed and filed by the provider consists minimally of the following components:
      1. DHS forms 183A and 183B completed in detail as directed by IDHS/Human Capital Development (HCD)/Family Community Resource Center (FCRC) /Client Assessment Unit (CAU) notification; Form 183A is best completed at time of discharge.
      2. The initial history and physical and relevant labs and diagnostic reports - may use provider's Form;
      3. The initial psychiatric evaluation (if not included in the history and physical evaluation) - may use provider's Form;
      4. The social history (or psycho-social evaluation)- may use provider's form;
      5. Progress notes reflecting the consumer's disabling conditions- may use provider's form(s);
      6. A Physician Discharge Summary, including the aftercare or post-discharge plan, completed as required by the Hospital - may use provider's form;
      7. Social Services discharge planning record including names, titles/credentials, addresses, and phone numbers of all follow up providers;
      8. Outpatient progress notes of community mental health service providers from the 12 month period prior to the CAU review;
      9. Responses by provider to any and all requests for subsequent information from DHS and/or CAU within required DHS timeframes (DHS form 267);
      10. The authorization for release of information to the Department of Human Services' Client Assessment Unit and the consumer's or hospital's local DHS office. Either the provider's release form or DHS' form may be used;
      11. The completion of Authorized Representative form (Il 444-2998) including designation of the Provider hospital or its designee and or designated discharge community provider as an authorized representative is strongly recommended.
        Note that refusal of a Consumer or family to complete the Medicaid or AllKids application is not considered an acceptable reason for a denied application qualifying for payment. Similarly, denials based on insufficiency of information or denials made at the request of the hospital or its agents are not considered an acceptable reason for a denied application and thus not qualifying for payment. Provider acknowledges that the failure to ensure that a complete application for Medicaid, AllKids, Veterans' Care or all other IDHFS eligibility programs, may result in the certification of payment being denied or delayed by IIDHS/DMH.

Exhibit B - Deliverables

  1. All admissions under the CHIPS program are to be reported by the Provider to the IIDHS/DMH Region Office within 24 hours of admission. These reports will include, but not be limited to, the Consumer's name or Illinois Department of Healthcare and Family Services (IDHFS) recipient identification number (RIN) or both, address, date of birth, provisional diagnosis and anticipated length of stay, unless such information is restricted by law.
  2. A copy of the Provider's Initial Psychiatric Evaluation is to be provided to the IIDHS/DMH within 24 hours after completion by the Provider's physician.
  3. The Patient (Consumer) Discharge Instruction Sheet (hospital-specific nursing discharge form) or Discharge Staff Note (hospital-specific form) or Discharge Staffing Form (Region-specific form) shall be provided to the designated after care providers (likely an IIDHS/DMH-funded community mental health service provider) and the IIDHS/DMH Region Office within 24 hours of discharge.
  4. A Physician Discharge Summary will be provided to the designated IIDHS/DMH-funded community mental health service provider and the IIDHS/DMH Region Office as soon as possible, after completion per Providers' policy or Provider's Medical Staff by-laws.
  5. The Provider will maintain, and upon request provide, verification of financial need as defined as the persons under 200% federal poverty level (FPL) as found at: 2012 HHS Poverty Guidelines - One Version of the [U.S.] Federal Poverty Measure  (http://aspe.hhs.gov/poverty/12poverty.shtml)
  6. The Provider will submit a payment voucher (Form C-13) to the respective DMH Region Offices for payment processing by IDHS that is reflective of CHIPS service activity (persons discharged) by the Provider for the previous month within 15 business days of the last day of the month.

Exhibit C - PAYMENT

Provider shall receive an estimated total compensation of $_______________ for services under this Agreement.

Enter specific terms of payment here:

  1. Inpatient psychiatric services and attending psychiatric physician services are reimbursed at $650.00 per day.
  2. Payments for exceptional psychiatrically-related medical services (as identified above) that have been requested by the Provider and have received prior approval by the IIDHS/DMH Region Office or that were required on an emergency basis and later approved. Payment will be based on the rates of the Illinois Department of Healthcare and Family Services (IDHFS) for such procedures.
  3. Payments will be based upon payment vouchers (Form C-13) being produced by the respective DMH Region Offices for payment processing by IDHS. The payment voucher amounts will be reflective of service activity by the Provider for the previous month.
  4. Payment will not be authorized or released until these forms are on file with IIDHS/DMH Region Office.
  5. Out-of-hospital passes or overnight passes off premises are not allowed. If either is issued, the day is not reimbursable under the terms of this Agreement.
  6. It is not the intent or purpose of this Agreement to displace or reimburse services for all or part of indigent or non-insured psychiatric services historically provided by this Provider.

Estimated Annual Contract Amount: $

NOTE: The estimated figures are merely an objective means of computing the contract amount and should not be construed as a guaranteed amount that will be spent on the contract during the fiscal year.

ATTACHMENT 1 - GUIDELINES FOR ADULT PSYCHIATRIC INPATIENT TREATMENT FOR CHIPS PATIENTS

To be eligible for the CHIPS program, the guidelines below must be followed.

A. GUIDELINES FOR ADMISSION FOR ACUTE HOSPITAL SERVICES

 The provider will maintain written documentation that the admission for acute hospital services is provided as active treatment, including that:

  1. The patient's condition affirms the need for required specialized resources and/or a structured environment in a selected facility for diagnosis, evaluation, or treatment and/or
  2. The patient's response to current treatment reflects that a less intensive or less restrictive psychiatric treatment program would not be adequate to provide safety for the patient or others or to improve the patient's functioning and
  3. An individualized treatment program is completed and on file that specifically addresses the therapeutic needs of the patient and, where appropriate, family involvement and
  4. Care is supervised and evaluated by a licensed physician who has completed an accredited psychiatric residency i.e., Accreditation Council for Graduate Medical Education or Accreditation of Colleges of Osteopathic Medicine and
  5. An expectation that the resources and techniques associated with this level of care will lead to successful discharge into the community or transfer to a less intensive or restrictive treatment program.

B. GUIDELINES FOR CONTINUED STAY:

 The provider will maintain written documentation that the Severity of Illness (SI) and Intensity of Service (IS) criteria are met as indicated below:

 SEVERITY OF ILLNESS (SI) (At a minimum, two criteria must be met.)

  1. The patient requires continuous skilled psychiatric observation, planned Psycho-therapeutic services, planned and controlled psychotropic drug management, and/or electro-convulsive therapy.
  2. The patient exhibits an inability to care for self due to an interaction of mental and other physical disorders creating incapacitating symptoms or behaviors.
  3. The patient poses a significant suicide risk, including meeting any of the following:
    • feeling hopelessness and/or worthlessness; or,
    • history of unpredictable behavior, agitation, impulsivity, or poor judgment; or,
    • patient history of previous suicide attempts; or,
    • persistent insomnia with deterioration in mood or cognition; or,
    • patient history of noncompliance with treatment recommendations in the past; or,
    • family history of suicide attempts or completed suicide; or,
    • patient history of abusing drugs that could lead to impulsiveness or poor judgment; or,
    • significant changes in mood or behavior; or,
    • patient history of recent loss (e.g., job, relationship, family member); or,
    • preoccupation with suicidal thoughts; or,
    • whether or not there is a suicide plan; or,
    • presence of a suicide plan with reasonable expectation for completion.
  4. The patient shows a history of assaultive or self-mutilative behavior or reported evidence of danger to self or others.
  5. The patient exhibits homicidal ideation accompanied by psychiatric disorder.
  6. The patient exhibits impaired reality testing accompanied by disordered behavior (e.g., bizarre, delusional, illogical thinking, hallucinations, manic behavior).

INTENSITY OF SERVICE (IS) (At a minimum, two criteria must be met.)

  1. Complex treatment necessitated by co-existing conditions requiring concurrent treatment (e.g., an insulin-dependent diabetic who is neglecting diabetic care due to major depression, chronic respiratory or cardiovascular insufficiency, etc.).
  2. A need for a controlled environment to protect self and others (e.g., suicide precautions, instituted isolation, etc.)
  3. Special treatment modalities available only in the hospital due to need for special environment, equipment, or ancillary services (e.g., planned and controlled psychotropic drug management). The need for inpatient electroconvulsive therapy will be evaluated on an individual basis and be based upon medical necessity.
  4. For patients with a high potential for near-term readmission [within 30 days] (e.g., documented history of recent admission or high risk behavior, poor adherence to last hospitalization's discharge plan, family's capacity to maintain the treatment plan, or identified need for specialized outpatient milieu), the medical record must reflect efforts taken to address these issues to prevent further readmissions.

C. GUIDELINES FOR DISCHARGE

The provider will maintain written documentation that the criteria for discharge as indicated below is met. (One of the following must be met.)

  1. The patient no longer poses a risk of harm to self or others.
  2. As indicated by a psychiatrist the presence of signs and symptoms sufficient to allow for functioning outside of the acute setting.
  3. The patient shows no evidence prompting a reasonable expectation of significant psychiatric improvement with continued inpatient treatment.
  4. Failure to initiate an initial therapeutic plan by the attending physician within 24 hours of admission and the multidisciplinary treatment plan if the patient remains in the hospital two days or longer, or both.
  5. No weekly revision to multidisciplinary treatment plan exists.

D. DOCUMENTATION GUIDELINES

 The following components of a patient's medical record have been defined to assist the admitting psychiatrist and ancillary staff in providing the necessary documentation indicative of active psychiatric care of intensity of service. The record must contain sufficient documentation for each item.

  1. Within 24 hours of admission, a psychiatric assessment (including the reason for admission, mental status examination, determination of diagnosis and identification of behavior/symptoms that need clinical intervention, and initial therapeutic plan based on identified needs) must be documented in the medical record by an attending physician.
  2. Other medical history and physical examination must also be completed within 24 hours of admission.
  3. If a patient remains in the hospital more than two days, a multidisciplinary treatment plan should be documented in the medical record by the attending physician, with input from other members of the treatment team on the 2nd day of hospitalization. The multidisciplinary treatment plan should be implemented on the 2nd day of hospitalization and include:
    • Clinical activities designed to enhance the patient's functioning sufficient for the patient to be transferred to a less restrictive care environment with a decreased likelihood of readmission.
    • Estimated timeframes to achieve goals including a re-evaluation if goals are not met, and changes needed; a new plan formulated if necessary.
  4. If a multidisciplinary treatment plan is warranted, multidisciplinary treatment plan/progress must be documented at least weekly.
  5. Regular progress notes should be completed by non-nursing, non-physician clinicians at least weekly.
  6. Physician involvement consistent with the acuity/complexity of the case. Physician involvement requires documentation in the form of a progress note. Attending physician's orders (written or verbal) or signature on the treatment plan are not substitutions for adequate physician involvement and documentation. The usual and customary standard is 6 progress notes per 7 day period/week. In order to reflect adequate attending physician involvement, resident physician documentation must reflect the patient was seen, and clinical interventions discussed with the attending physician.
  7. Skilled psychiatric nursing must be reflected in the medical record daily and must contain an appropriate sample of clinical nursing observations and interchanges between the patient and nursing staff. In addition, an assessment of the patient for therapeutic and side effects of medications should be documented.
  8. Discharge planning needs/efforts must be documented weekly in the medical record and should be part of the team's weekly evaluation of achievable goals. In addition, appropriate and timely follow-up arrangements should be documented and include a scheduled follow-up appointment.
  9. An explanation at the time of discharge should be documented if an appointment cannot be arranged. Patient refusal of suggested follow-up arrangements should be documented.
  10. Treatment may necessitate discontinuance of therapy for a period of time, or a period of observation as preparation for therapy, or as a follow-up to therapy, while maintenance or protective services are provided. If these are essential to the overall plan, they are part of active treatment.
  11. For patients with a high potential for near-term readmission within 30 days (e.g., documented history of recent admission or high risk behavior, poor adherence to last hospitalization's discharge plan, family's capacity to maintain the treatment plan, or identified need for specialized outpatient milieu), the medical record must reflect efforts taken to address these issues to prevent further readmissions.