Common use of Community-Based Services Clause in Contracts

Community-Based Services. 24. For every child in the target population for whom community-based services are appropriate and whose family or guardian does not oppose community-based services or in the case of children aged 18 or over, the individual does not oppose community- based services, DHHR shall ensure timely access to In-Home and Community-Based Services sufficient to meet the individual’s needs including Wraparound Facilitation, Behavioral Support Services, Children’s Mobile Crisis Response, Therapeutic ▇▇▇▇▇▇ Family Care, and Assertive Community Treatment. These services will be provided in a manner that enable the child to remain with or return to the family (or ▇▇▇▇▇▇ or kinship care family or an independent living setting, where applicable) whenever possible. DHHR shall ensure statewide access to these programs to prevent crises and promote stability in the family home (or ▇▇▇▇▇▇ or kinship care home, where applicable). 25. These in-home and community-based services offered to the target population are intended to advance the state’s compliance with the ADA for the target population and to ensure these services, programs, and activities are provided to the target population in the most integrated setting appropriate to meet their needs. 26. In-home and community-based services will be delivered at times and locations mutually agreed upon by the provider and the child and family (or ▇▇▇▇▇▇ or kinship care family, where applicable), to assist the child in practicing skill development in the context of daily living. 27. Nothing in this agreement shall override the right of a child in the target population, or his or her guardian for a child under 18, to refuse offered services. 28. DHHR shall ensure the timely provision of mental health services to address any immediate or urgent need for services. Such services will be provided through consultation with the child and family (or ▇▇▇▇▇▇ or kinship parent, where applicable) and include needed in-home and community-based services and linkage to other service providers. 29. Children’s Mobile Crisis Response shall be available to all children, regardless of eligibility, to prevent unnecessary institutionalization of children with serious mental health crises. Children’s Mobile Crisis Response shall provide toll-free crisis hotline services and Crisis Response Teams that are available throughout the state and staffed 24-hours per day, seven days per week. Callers will be directly connected to a trained mental health professional with experience or competency-based training in working with children in crisis. 30. DHHR shall develop criteria in its implementation plan to guide decisions by crisis hotline staff whether to attempt to resolve the crisis by phone or dispatch a Crisis Response Team. At a minimum, the implementation plan will contain: a. Criteria for how the hotline staff will assist with immediate stabilizations; b. Requirements that hotline staff have access to needed information regarding the child and family when the family provides consent (including any existing crisis plans and the Individualized Service Plan); c. Guidelines for hotline staff to assess the crisis to determine whether it is appropriate to resolve the crisis through a phone intervention or a face-to-face intervention; d. A requirement that each region of the state has sufficient Crisis Response Team(s) to serve the entire region and to respond face-to-face to a call within an average time of one hour; and e. Data collection to assess and improve the quality of crisis response, including the timeliness of the crisis response and subsequent intake process, and effectiveness of engaging families in home and community based services following the crisis. 31. DHHR shall ensure that all children who are eligible to receive mental and physical health care and services through DHHR are screened to determine if they should be referred for further mental health evaluation or services. DHHR shall adopt a standardized set of mental health screening tools for use in identifying who may be in the target population. A mental health screen shall be completed for any child not already known to be receiving mental health services when: the child enters DHHR Youth Services, the child welfare system, or the juvenile justice system; or the child or family (or ▇▇▇▇▇▇ or kinship care family, where appropriate) requests mental health services or that a screen be conducted. In addition, DHHR shall conduct outreach and training on the use of the screening tools to physicians who serve children who are Medicaid-eligible. Fifty-two percent of Medicaid-eligible children who are not in the Youth Services, child welfare, or juvenile system systems shall be screened with the mental health screening tool annually. 32. For a child whose screening indicates a need for further evaluation or services, for whom placement in a Residential Mental Health Treatment Facility is recommended or has been made, or who has received mental health crisis intervention, DHHR shall timely provide an intake and assessment process which includes a face-to-face meeting with a community provider, the child, and family (or ▇▇▇▇▇▇ or kinship parent, where applicable), to identify the child’s need for in-home and community-based services. It is presumed that all children who reside in a Residential Mental Health Treatment Facility on the Effective Date, or who are placed in a Residential Mental Health Treatment Facility after the Effective Date, need in-home and community-based services. 33. DHHR shall ensure statewide access to Wraparound Facilitation for each child identified as needing in-home and community-based services, per paragraph 32, to allow for meaningful family involvement and timely provision of services. In Wraparound Facilitation, the Child and Family Team shall manage the care of the child, and the Wraparound Facilitator shall lead the Child and Family Team. 34. DHHR shall ensure that each Child and Family Team operates with high fidelity to the National Wraparound Initiative’s model. 35. DHHR will use the Child and Adolescent Needs and Strengths (CANS) tool (or similar tool approved by both parties) to assist the Child and Family Team in the development of Individualized Service Plans for each child who has been identified as needing in- home and community-based services, per paragraph 32. A qualified individual, as further determined by the Parties and defined in the implementation plan, shall conduct an assessment of the child’s needs with the CANS. The Wraparound Facilitator shall lead the development of the Individualized Service Plan. For children who are in Residential Mental Health Treatment Facilities, the Individualized Service Plan shall include discharge planning. 36. For any child who has a Multidisciplinary Treatment Team (MDT), DHHR shall provide the child’s screening, assessments, and Individualized Service Plans to the MDT. 37. DHHR, in cooperation with the Department of Education and the Department of Military Affairs and Public Safety, shall provide services in the child’s family home (or ▇▇▇▇▇▇ or kinship care home, where applicable) and in the community. The services that may be necessary for children in the target population include: a. Family support and training services that provide education and training for the child’s family (or ▇▇▇▇▇▇ or kinship care, where applicable) about the child’s condition and how the family can best support the child in the home and community; b. Behavioral Support Services; and c. In-home therapy that provides a structured, consistent, strengths-based therapeutic relationship between a licensed clinician, the child, and family (and ▇▇▇▇▇▇ or kinship care family, where applicable) for the purpose of effectively addressing the child’s mental and behavioral health needs. 38. DHHR shall expand Therapeutic ▇▇▇▇▇▇ Family Care statewide. DHHR shall develop Therapeutic ▇▇▇▇▇▇ Family Homes and provider capacity in all regions and shall ensure that all children who need this service are timely placed in a Therapeutic ▇▇▇▇▇▇ Family Home with specially trained therapeutic ▇▇▇▇▇▇ parents, in their own community whenever possible. 39. DHHR shall ensure ACT, which DHHR began providing in 2003, is available statewide, and that members of the target population between the ages of 18 to 20 who need ACT receive it timely. ACT teams may substitute for the Child and Family Team under the terms of this agreement. Where the ACT teams substitute for the Child and Family Teams, the ACT teams shall develop the Individualized Service Plan; and provide or ensure access to needed in-home and community-based services. 40. DHHR shall provide high quality in-home and community-based mental health services that are timely and individualized to the child’s needs. DHHR shall ensure that children receive, as needed, all of the in-home and community-based services described in this agreement. DHHR shall ensure that each of these services is available and accessible statewide to children in the target population in the necessary amount, location, and duration. DHHR shall provide families and children with accurate, timely, and accessible information regarding the available in-home and community-based services in their communities. 41. DHHR shall create an implementation plan that describes the actions it will take to ensure that the programs described herein are sustainable, statewide, and available to children in the target population. Specifically, the plan shall contain the steps DHHR will take to: a. Ensure statewide access to the programs and services in this agreement; b. Evaluate the adequacy of crisis response and address any inadequacies; c. Evaluate the fidelity of child and family teams to the National Wraparound model; d. Address workforce shortages relating to services under this agreement; e. Evaluate the provider capacity needed to address the agreement; f. Develop outreach tools for medical professionals who treat Medicaid-eligible children; g. Develop quality assurance and performance improvement measures; and h. Achieve the reduction in the number of children unnecessarily placed in Residential Mental Health Treatment Facilities described in paragraph 52c.. 42. Within 120 days of the Effective Date, DHHR shall provide a draft of its implementation plan to the United States, which shall provide comments within 30 days of receipt. The State shall timely revise its implementation plan to address comments from the United States, and the Parties shall meet and consult as necessary. After the State has revised the implementation plan, it shall invite and consider public comment before finalizing the implementation plan. The state shall make its implementation plan publicly available. At least annually, the State shall review its implementation plan and submit any revisions to DOJ and to the public for comment before making the revised plan publically available, following the same process outlined above. The implementation plan shall outline the necessary steps so that all programs are available statewide by October 1, 2020. 43. The implementation plan and all supplements and schedules shall become enforceable provisions of this agreement.