Gila River Health Care Corporation
Gila River Health Care Corporation
PROVIDER MANUAL
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Arizona Department of Health Services

Division of Behavioral Health Services
PROVIDER MANUAL
Gila River Regional Behavioral Health Authority Edition


Section 3.22 Out-of-State Placements for Children and Young Adults

3.22.1 Introduction
3.22.2 Terms
3.22.3 Procedures
3.22.3-A: General requirements
3.22.3-B: Conditions before a referral for out-of-state placement is made
3.22.3-C: The Individual Service Plan (ISP)
3.22.3-D: Initial notification
to ADHS/DBHS Office of Medical Management
3.22.3-E Required updates to ADHS/DBHS Office of Medical Management
3.22.3.F Required Reporting of an Out-of-State Provider
3.22.4 References

3.22.1 Introduction
At times, it may be necessary to consider an out-of-state placement for a child or young adult to meet the person’s unique circumstances or clinical needs. The following factors may lead a person’s Child and Family Team (CFT) or Adult Recovery Team (ART) to consider the temporary out-of-state placement of a child or young adult.

  • A child or young adult needs specialized programming not currently available in Arizona to effectively treat a specified behavioral health condition;
  • An out-of-state placement’s approach to treatment incorporates and supports the child’s or young adult’s unique cultural heritage;
  • A lack of current in-state bed capacity and/or
  • Geographical proximity encourages support and facilitates family involvement in the person’s treatment.

The Arizona Department of Health Services/Division of Behavioral Health Services (ADHS/DBHS) expects that decisions to place children or young adults in out-of-state placements for behavioral health care and treatment are examined closely and made after the CFT or ART have reviewed all other in-state options. Other options may include the provision of support services in the context of the person’s current living situation, single case agreements with in-state providers or the development of an Individual Service Plan (ISP) that incorporates a combination of support services and clinical interventions. In the event that an out-of-state placement is clinically necessary and supported by the Child and Family Team and/or Adult Clinical Team, Tribal and Regional Behavioral Health Authorities (T/RBHAs) and their providers must follow the steps and procedures outlined in this section. Services provided out-of-state must meet the same requirements as those rendered in-state. T/RBHAs must also ensure that out-of-state providers follow all AHCCCS reporting requirements as well as ADHS/DBHS policies and procedures, including appointment standards and timelines specified in Section 3.2, Appointment Standards and Timeliness of Service.

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3.22.2 Terms
Definitions for terms are located online at http://www.azdhs.gov/bhs/definitions/index.php. The following terms are referenced in this section:

Adult Recovery Team (ART)

Certification of Need (CON)

Child and Family Team (CFT)

Individual Service Plan (ISP)

Prior Authorization (PA)_PM3.22

Single Case Agreement

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3.22.3 Procedures

3.22.3-A. General Requirements
When the T/RBHA is considering an out-of-state placement for a child or young adult, the following conditions apply:

  • The CFT or ART will consider all applicable and available in-state services and determine that the services do not adequately meet the specific needs of the person;
  • The person’s family/guardian is in agreement with the out-of-state placement (for minors and persons between 18 and under 21 years of age under guardianship);
  • The out-of-state placement is registered as an AHCCCS provider;
  • The out-of-state placement meets the Arizona Department of Education Academic Standards; and
  • A plan for the provision of non-emergency medical care must be established.

3.22.3-B: Conditions before a referral for out-of-state placement is made
Documentation in the clinical record must indicate that the following conditions have been met before a referral for an out-of-state placement is made:

  • All less restrictive clinically appropriate approaches have either been provided or considered by the CFT or ART  and found not to meet the person’s needs;
  • A minimum of three in-state facilities have declined to accept the person;
  • The CFT or ART has been involved in the service-planning process, and is in agreement with the out-of-state placement;
  • The CFT or ART has documented how they will remain active and involved in service planning once the out-of-state placement has occurred;
  • An ISP has been developed (see Section 3.9, Assessment and Service Planning);
  • All applicable prior authorization requirements have been met (see Section 3.14, Securing Services and Prior Authorization);
  • The Arizona Department of Education has been consulted to ensure that the educational program in the out-of-state placement meets the Arizona Department of Education Academic Standards and the specific educational needs of the person;
  • Coordination has occurred with all other state agencies involved with the person including notification to the Medical Director of the Division of Developmental Disabilities (DDD) when the individual is enrolled with DDD and the Medical Director of The Comprehensive Medical and Dental Plan (CMDP) when the individual is enrolled with CMDP;
  • The person’s primary care provider and AHCCCS Acute Health Plan have been contacted and a plan for the provision of any necessary non-emergency medical care has been established and is included in the comprehensive clinical record by the assigned Gila River RBHA Clinician (Clinical Liaison); and
  • In the event that a person has been placed out-of-state due to an emergency situation or unforeseen event, the T/RBHA must address all applicable above conditions as soon as notification of the out-of-state placement is received.

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3.22.3-C: Individual Service Plan (ISP)
For a person placed out-of-state, the ISP developed by the CFT or ART must require that:

  • Discharge planning is initiated at the time of referral or notification of admission, including:
    • The measurable treatment goals being addressed by the out-of-state placement and the criteria necessary for discharge back to in-state services;
    • The possible or proposed in-state residence where the person will be returning
    • The recommended services and supports required once the person returns from the out-of-state placement;
    • What needs to be addressed or arranged to accept the person for subsequent in-state placement to meet the person’s needs;
    • How effective strategies implemented in the out-of-state placement will be transferred to the persons’ subsequent in-state placement;
    • The actions necessary to integrate the person into family and community life upon discharge;
    • The CFT or ART actively reviews the person’s progress with clinical staffings occurring at least every 30 days; and
    • Clinical staffings must include the staff of the out-of-state facility.
  • The person’s family/guardian is involved throughout the duration of the placement. This may include family counseling in person or by teleconference or videoconference;
    • The CFT or ART must ensure that essential and necessary health care services are provided; and
    • Home passes are allowed as clinically appropriate and in accordance with the ADHS/DBHS Covered Behavioral Health Services Guide. For youth in Arizona Department of Child Safety (ADCS) custody, home passes must be determined only in close collaboration with ADCS.
  • The person's needs, strengths and cultural considerations have been addressed.

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3.22.3-D. Initial notification to ADHS/DBHS Office of Medical Management
What is the process for providing initial notification to ADHS/DBHS?
T/RBHAs are required to notify ADHS/DBHS Office of Medical Management immediately upon notification that a member has been emergently placed in an out-of-state Behavioral Health Hospital Facility, using the Out-of State Placement Form. The Out of State Placement Form will be posted as part of the Bureau of Quality and Integration (BQ& I) Specifications Manual.

T/RBHAs are required to notify ADHS/DBHS Office of Medical Management prior to a referral for out-of-state placement and upon discovering that a T/RBHA enrollee is in an out-of-state placement, using PM Form 3.22.1, Out-of-State Placement. Prior authorization must be obtained prior to making a referral for out-of-state placement, in accordance with T/RBHA criteria (See Section 3.14, Securing Services and Prior Authorization). T/RBHAs may ask that providers assist with supplying the information required on the form and with providing copies of supporting clinical documentation.

Prior to placing the child or young adult in an out-of-state residential treatment facility or upon discovering that a T/RBHA enrollee has been admitted to an out-of-state behavioral health hospital, the T/RBHA or behavioral health provider must complete the Out-of-State Placement Form and submit an electronic copy to ADHS/DBHS Office of Medical Management via secure e-mail to DBHSMEDICALMANAGEMENT@azdhs.gov for approval of planned out-of-state placements or notification of emergency behavioral health hospitalizations. Completed forms must be submitted in electronic format only.

The RBHA must develop and make available policies and procedures that clearly indicate that the RBHA or the behavioral health provider will submit the required reporting form to ADHS/DBHS Office of Medical Management as described in the first two paragraphs of 3.22.3-D

ADHS/DBHS will review the information in the Out of State Placement Form and if the information is incorrect or incomplete the form will be sent back to the T/RBHA’s for correction and reprocessed for approval.

3.22.3-E Required updates to ADHS/DBHS Office of Medical Management
In addition to providing initial notification, the T/RBHA is required to submit electronic updates to ADHS/DBHS Office of Medical Management regarding the person’s progress in meeting the identified criteria for discharge from the out-of-state placement every thirty (30) days, or within 48 hours after notification of discharge from the out of state facility. Thirty (30) days refers to calendar days and 48 hours refers to business days with business days excluding weekends and holidays. If a thirty (30) day update date falls on a weekend or holiday, it will be submitted on the next business day. To adhere to this requirement, T/RBHAs must use the Out of State Placement Form. T/RBHAs may ask that providers assist with providing the information required on the form.

Once completed T/RBHAs must submit the form in electronic format to the ADHS/DBHS Office of Medical Management via secure e-mail to: DBHSMEDICALMANAGEMENT@azdhs.gov every thirty (30) days that the person continues to remain in out-of-state placement. The thirty (30) day update timeline will be based upon the date of DBHS approval of the out-of-state placement. T/RBHAs must utilize and make available the reporting forms related to the thirty (30) day update in their policies and procedures as described in Policy 408, sections 3.e.i. and 3.e.ii.

Gila River BHS may require its subcontracted behavioral health providers to provide information to include on the Out of State Placement Form. In addition, out-of-state providers are required to provide periodic clinical information to the assigned RBHA Clinician in a reporting format approved by Gila River BHS.

3.22.3-F Required Reporting of Out-of-State Provider

All Out-of-State providers are required to meet the reporting requirements of all incidences of injury/accidents, abuse, neglect, exploitation, healthcare acquired conditions, injuries from seclusion/restraint implementations as described in Section 7.3 Seclusion and Restraint Reporting.

3.22.4 References
The following citations can serve as additional resources for this content area:

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3.22 Out-of-State Placements for Children and Young Adults
Last Revised: 7/31/2015
Effective Date: 7/31/2015

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