INTRODUCTION

shutterstock_39807499Therapeutic Behavioral Services (TBS) are the result of a judgment and permanent injunction in Emily Q. v. Bonta (C.D.Cal., 2001, CV98-4181 AHM (AIJx)).  TBS is an EPSDT supplemental service for children/youth with serious emotional problems who are experiencing a stressful transition or life crisis.  Eligibility criteria are delineated in the following general provisions and are required in addition to the need for service.  TBS is intended to be supplemental to other specialty mental health services by addressing specific target behavior(s) or symptom(s) that jeopardize a child/youth’s current living situation or planned transition to a lower level placement.  The purpose of providing Therapeutic Behavioral Services is to further the child/youth’s overall treatment goals by providing focused additional therapeutic services during a short-term period.

The person providing therapeutic behavioral services is available on site to provide individualized one-to-one behavioral assistance and one-to-one interventions to accomplish outcomes specified in the written treatment plan.  The critical distinction between
Therapeutic Behavioral Services and other rehabilitative Mental Health Services is that a significant component of this service activity is having the staff person on site and immediately available to intervene for a specified period of time.  The expectation is that the staff person would be with the child/youth for a designated time period and the entire time the mental health provider spends with the child/youth in accordance with the treatment plan would be reimbursable.  These designated time periods may vary in length and may be up to 24 hours a day, depending upon the needs of the child/youth.

PURPOSE

Need for this service includes additional short-term support to prevent placement in a higher level of residential care or a locked facility for the treatment of mental health needs, including acute care, or to enable a transition from any of those levels to a lower level of residential care.

GENERAL PROVISIONS

TBS Criteria

A.  Eligibility

  1. Must be a full scope Medi-Cal beneficiary under 21 years old.
  2. Must meet MHP medical necessity criteria

B.  Member of the Certified Class – must meet one of the following criteria.

  1. Child/youth is placed in a group home facility of Rate Classification Level (RCL) 12 or above and/or a locked treatment facility for treatment of mental health needs which is not an institution for mental health disease, or
  2. Child/youth has undergone at least one emergency psychiatric hospitalization related to his/her current presenting disability within the preceding 24 months, or
  3. Child/youth is being considered by the county for placement in a group home facility of RCL12 or above and/or a locked treatment facility, or
  4. Child/youth previously received Therapeutic Behavioral Services while a member of the certified class.

C.  Need for TBS

  1. The child/youth is receiving other specialty mental health services.
  2. Without these additional short-term services it is highly likely that in the clinical judgment of the mental health provider:

a. The child/youth will need to be placed in a higher level of residential care, including acute care because of a change in the child/youth’s behaviors or symptoms which jeopardize continued placement in the current facility, or

b.The child/youth needs additional support to transition to a lower level of residential placement.  Although the child/youth may be stable in the current placement, a change in behavior or symptoms are expected and therapeutic behavioral services are needed to stabilize the child/youth in the new environment.

IMPLEMENTATION REQUIREMENTS

Response Time

TBS services are considered an intensive service with 24-hour capability.  Charis will respond to any TBS referral received in the following manner:

  • Phone contact is made with the Treatment Team the same day the referral is authorized and received.  If the referral is received after normal business hours, telephone contact will be made with the on-call mental health staff.
  • Charis will have a face-to-face meeting with the Treatment Team no later than two business days of receiving the referral.
  • There must be documented evidence of the first therapeutic contact occurring no later than two business days of the receipt of the referral.  If no contact could be made with the client, parent or caretaker, there must be a progress note indicating a reasonable explanation and a plan to make contact as soon as possible.
  • Any deviation from this established response time policy must be documented specifically surrounding the circumstances.  Under no circumstances should TBS services be delayed in expectation of coordination or facilitation.

Service Delivery

Therapeutic Behavioral Services (TBS) are an EPSDT one-to-one therapeutic contact between a mental health provider staff and child/youth plan member for a short period of time.  A contact is considered therapeutic if it is intended to provide the child/youth with skills to effectively manage the behavior(s) or symptom(s) that impedes achieving residence in the lowest appropriate level.  TBS services include direct one-to-one contact with the client, one-to-one contact with family or caregivers (collateral), or one-to-one plan development services with the client or caregiver.

Case Management Brokerage is billable for inter and intra-agency consultation or coordination of services and any discussion of the TBS plan that does not include the client or caregiver.

Oversight by a Licensed Practitioner of the Healing Arts (LPHA) will be provided for all TBS services planned and provided.  TBS services will be provided by an LPHA or trained staff members who are under the direction of an LPHA.  TBS is focused on resolution of target behaviors or symptoms which jeopardize existing placements or which are a barrier to transitioning to a lower level of residential placement and completion of specific treatment goals.  In keeping with the State Department of Mental Health direction for TBS, Charis’ expectation is that the majority of TBS services are direct one-to-one contact with the client.

Service Description

Prior to the provision of TBS, an assessment for medical and service necessity is determined.  Services must be pre-approved by the client’s referring county mental health department and a monthly review of the effectiveness of TBS is required.  The client’s treatment plan that includes TBS is based on a comprehensive assessment of the client’s (and family’s, if applicable) strengths and needs.  When possible and appropriate, the plan will be developed with the client’s family.  The TBS component of the treatment plan should be: 1) adjusted to identify new target behaviors, interventions, and outcomes as necessary and appropriate, and 2) reviewed and updated as necessary whenever there is a change in the client’s treatment progress.  Progress notes are completed for each time period that a mental health provider spends with the client.

This service activity is focused on resolution of target behaviors or symptoms which jeopardize existing placements or which are a barrier to transitioning to a lower level of residential placement and completion of specific treatment goals.  Therapeutic behavioral services are to be decreased when indicated and discontinued when the identified behavioral benchmarks have been reached or when reasonable progress towards the behavioral benchmarks are not being achieved and are not reasonably expected, in the clinical judgment of the Treatment Team, to be achieved.

Examples of activities/interventions may include but are not limited to:

  • Assisting the client to engage in, or remain engaged in, appropriate activities.
  • Helping to minimize the client’s impulsive behavior.
  • Helping to increase the client’s social and community competencies by building or reinforcing those daily living skills that will assist the client in living successfully at home and in the community.
  • Providing immediate behavior reinforcements.
  • Providing time-structuring activities.
  • Preventing inappropriate responses.
  • Providing appropriate time-out strategies.
  • Providing cognitive behavioral approaches, such as cognitive restructuring, use of hierarchies, and graduated exposure.
  • Collaboration with and support for the family caregivers’ efforts to provide a positive environment for the child.

Cultural Competency

Culturally and linguistically competent services are required of all Mental Health Plan Providers.  Culturally appropriate and linguistically proficient service strategies are to be integrated into all services at both client plan development and treatment level.

Charis is committed to providing culturally competent treatment services to children, youth, and families we serve. To this end, we have hired a diverse staff bring together a broad range of cultures.  We employ bi-lingual, spanish-speaking staff that are available to the TBS program.

Caregiver Involvement

Caregiver involvement is an integral part of TBS service delivery.  The client’s county Department of Mental Health and Charis are involved in plan development for target behaviors and ongoing review of goal attainment.  TBS services include providing feedback on progress and skill building to assist caregivers in successfully integrating changes in the client’s behavior into daily living.

Providing a signed client TBS service plan to the client and/or caregiver is the responsibility of Charis.  Such a plan represents the roles and responsibilities of different participants in successful service delivery.

Coordination

Coordination of care is an essential element in the implementation of TBS.  Charis must regularly inform the client’s county of the TBS plan and the progress of the interventions.  Charis must provide LPHA oversight as the primary coordinator of services for the child/youth.  Providing assistance to the family or caregivers is required as part of the transition plan.  Intra- and inter agency coordination is also expected to occur as a part of the transition plan.  The two programs providing service to the client shall meet monthly face to face, at minimum, to ensure LPHA oversight and the provision of a quality, unduplicated service to the child/youth.

Transition

There must be a written transition plan with involvement from the client and caregiver at the onset of TBS to address decreasing and/or discontinuing therapeutic behavioral services when they are no longer needed or appear to have reached a plateau in benefit effectiveness.  When applicable, there must be a plan for transition to adult services when the beneficiary turns 21 years old and is no longer eligible for TBS.  This should include assisting parents and/or caregivers with skills and strategies to provide continuity of care when this service is discontinued.  Therapeutic Behavioral Services are to be decreased when indicated and discontinued in the following circumstances:

a.    When the identified behavioral benchmarks have been reached or,
b.    When reasonable progress towards the behavioral benchmarks are not being achieved and
c.    When progress has reached a plateau and in the clinical judgment of the MHP’s provider no further progress is anticipated.

TBS services are intended to be short-term, time-limited services and not appropriate to maintain a child/youth at a specified level for the long-term.

Documentation

There must be a written plan for Therapeutic Behavioral Services as a component of an overall treatment plan for specialty mental health services.  A copy of the most recent Assessment Client Plan (ACP) or Re-assessment & Re-authorization Plan (R&R) is located in the client’s clinical file.  Charis will complete the TBS Client Plan (Addendum to the ACP/R&R) within three (3) business days of the first face-to-face appointment.

If Therapeutic Behavioral Services are continued beyond the initial authorization, Charis will submit a request for additional authorization five (5) calendar days prior to the end of the current TBS authorization.  The request for additional TBS authorization will include a completed TBS Client Plan (Addendum to the ACP/R&R).

A progress note is required for each time period that a mental health provider spends with the child/youth.

  • The date on the progress note will coincide with the actual service date.
  • Progress notes will include the identified target behavior, significant interventions used, the client’s response, and progress in relation to transition.
  • Progress notes do not have to justify all billed minutes with documentation of staff intervention or activities.  However any designated time period spent with a client will be documented as being in accordance with the treatment plan.
  • Progress notes will be recorded in minutes.  Start and End of direct service time shall be noted, including travel time (e.g., 8:00 a.m. to 1:30 p.m.).  Staff travel and documentation time are Medi-Cal reimbursable if they are linked to a service.
  • Signatures on progress notes will be legible and include title, accorded by the MHP, or licensure.  Co-signature requirements are the same as any other mental health service.

Monthly Reviews

The TBS plan will be reviewed monthly in collaboration with the client, parent/caretaker, and client’s county Mental Health Department to identify new target behaviors, interventions, and outcomes as necessary and appropriate.

Upon the fourth consecutive and any further authorization, Quality Assurance may review the client’s chart for monitoring, oversight, and quality assurance.

Problem Resolution

Because TBS is a time limited, adjunct service it is understood that Charis will have given the client and/or caregiver the Mental Health Plan’s Member Handbook and Problem Resolution Guide.  Charis will have the Problem Resolution materials readily accessible and phone numbers available for clients’ and caregivers’ use.

Staffing

TBS staff is available to provide individualized one-to-one behavioral assistance and one-to-one interventions to accomplish outcomes specified in the written TBS treatment plan.  The critical distinction between TBS and intensive case management is that the staff shall be continuously and immediately available to intervene for a specified period.  TBS staff is not available for any other activity at this time; they are with the client for a designated period and the entire time spent with the client in accordance with the treatment plan is reimbursable.  These designated periods may vary in length and may be up to 24 hours a day, depending upon the needs of the client and treatment plan interventions and strategies.

Therapeutic Behavioral Services are provided under the direction of a Licensed Practitioner of the Healing Arts (LPHA):

  • Physician
  • Licensed / “waivered” Psychologist
  • Licensed / registered / waivered Clinical Social Worker
  • Licensed / registered / waivered Marriage Family and Child Counselor
  • Licensed Registered Nurse (with a master’s degree)

Unlicensed staff approved to provide the service include:

  • Staff with a bachelor’s degree in a mental health related field
  • Staff with two years of full time equivalent experience in delivering services in the mental health field
  • Staff without a bachelor’s degree in a mental health field or two years of experience (requires co-signature requirements)

Staff Training

Charis Youth Center’s training program currently meets and exceeds the requirements of Title 22 for Community Care licensed facilities for training. In addition to this training plan, the TBS staff will be provided with 10 hours of training emphasizing community-based interventions, work with families, and designing individualized interventions for targeted behaviors.  In addition, ongoing in-service training will be provided weekly in conjunction with staff meetings and treatment planning meetings.  Below is an outline for the training program to be utilized for the TBS staff:

Initial TBS Training Program (to be provided as an adjunct to Charis’ Orientation, Therapeutic Crisis Intervention, and Life Space Crisis Intervention training):

Working with Youth in Community Settings (2 hours)

Caregivers as Partners (2 hours)

Creating Specific and Measurable Treatment Goals (1 hour)

Designing Cognitive Behavioral Interventions (1hour)

The Family Conference Team – strategies and facilitation (2 hours)

TBS Documentation Requirements (2 hours)

Billing

Charis will not bill for missed appointments.  Documentation time shall be included in the billable time for the date the service was provided.