Gila River Health Care Corporation
Gila River Health Care Corporation
PROVIDER MANUAL
Go to Manual Table of Contents
Go to Next Manual Section
Go to Previous Manual Section
Return to Home Page

Arizona Department of Health Services

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


Section 3.8 Outreach, Engagement, Re-engagement, and Ending an Episode of Care and Disenrollment

3.8.1 Introduction
3.8.2 Terms
3.8.3 Procedures
3.8.3-A: Outreach
3.8.3-B: Engagement
3.8.3-C: Re-engagement
3.8.3-D: Ending an Episode of Care for a person in the behavioral health system
3.8.3-E: Serving a person previously enrolled in the behavioral health system
3.8.4 References


3.8.1 Introduction

The activities described within this section are an essential element of clinical practice. Outreach to vulnerable populations, establishing an inviting and non-threatening clinical environment, and re-establishing contact with persons who have become temporarily disconnected from services are critical to the success of any therapeutic relationship.

This section addresses five critical activities that behavioral health providers must incorporate when delivering services within Arizona’s public behavioral health system:

  • Expectations for outreach activities directed to persons who are at risk for the development or emergence of behavioral health disorders;
  • Expectations for the engagement of persons seeking or receiving behavioral health services;
  • Procedures to re-engage persons in an episode of care who have withdrawn from participation in the treatment process;
  • Conditions necessary to end an episode of care for a person in the behavioral health system; and
  • Expectations for serving persons who are attempting to re-enter the behavioral health system.

Go to top

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

Disenrollment

Engagement

Episode of Care

Outreach

Re-engagement

Go to top

3.8.3 Procedures

3.8.3-A: Outreach
Overview of Outreach Activities
The behavioral health system must provide outreach activities to inform the public of the benefits and availability of behavioral health services and how to access them. T/RBHAs must disseminate information to the general public, other human service providers, school administrators and teachers and other interested parties regarding the behavioral health services that are available to eligible persons.

Outreach activities conducted by the T/RBHAs may include, but are not limited to:

  • Participation in local health fairs or health promotion activities;
  • Involvement with local schools;
  • Routine contact with AHCCCS Health Plan behavioral health coordinators and/or primary care providers;
  • Development of homeless outreach programs;
  • Development of outreach programs to persons who are at risk, are identified as a group with high incidence or prevalence of behavioral health issues or are underserved;
  • Publication and distribution of informational materials;
  • Liaison activities with local and county jails, county detention facilities, and local and county CPS offices and programs;
  • Routine interaction with agencies that have contact with substance abusing pregnant women/teenagers;
  • Development and implementation of outreach programs that identify persons with co-morbid medical and behavioral health disorders and those who have been determined to have a Serious Mental Illness (SMI) within the T/RBHA’s geographic service area, including persons who reside in jails, homeless shelters, county detention facilities or other settings;
  • Provision of information to mental health advocacy organizations; and
  • Development and coordination of outreach programs to Native American tribes in Arizona to provide services for tribal members.

In addition to the above, Gila River Behavioral Health Services targets outreach to the following tribal agencies and providers serving members of the Gila River Indian Community:

  • Tribal Social Services (TSS);
  • Gila River Police, Fire and EMS; and
  • Primary medical providers through Indian Health Services (IHS).

Go to top

3.8.3-B: Engagement

T/RBHAs or their subcontracted providers must actively engage the following in the treatment planning process:

  • The person and/or person's legal guardian;
  • The person’s family/significant others, if applicable and amenable to the person;
  • Other agencies/providers as applicable; and
  • For persons with a Serious Mental Illness who are receiving Special Assistance (see Section 5.4, Special Assistance for Persons Determined to Have a Serious Mental Illness), the person (guardian, family member, advocate or other) designated to provide Special Assistance.

Behavioral health providers must provide services in a culturally competent manner in accordance with the T/RBHSs’ Cultural Competency Plan.

Go to top

3.8.3-C: Re-engagement
Behavioral health providers must attempt to re-engage persons in an episode of care who have withdrawn from participation in the treatment process prior to the successful completion of treatment, refused services or failed to appear for a scheduled service. All attempts to re-engage persons who have withdrawn from treatment, refused services or failed to appear for a scheduled service must be documented in the comprehensive clinical record. The behavioral health provider must attempt to re-engage the person by:

  • Communicating in the person's preferred language;
  • Contacting the person or the person’s legal guardian by telephone, at times when the person may reasonably be expected to be available (e.g., after work or school);
  • Whenever possible, contacting the person or the person's legal guardian face-to-face, if telephone contact is insufficient to locate the person or determine acuity and risk;
  • Sending a letter to the current or most recent address requesting contact, if all attempts at personal contact are unsuccessful, except when a letter is contraindicated due to safety concerns (e.g., domestic violence) or confidentiality issues. The provider will note safety or confidentiality concerns in the progress notes section of the clinical record and include a copy of the letter sent in the comprehensive clinical record; and
  • For persons determined to have a Serious Mental Illness who are receiving Special Assistance (see Section 5.4, Special Assistance for Persons Determined to have a Serious Mental Illness), contacting the person designated to provide Special Assistance for his/her involvement in re-engagement efforts.

If the above activities are unsuccessful, the behavioral health provider must make further attempts to re-engage persons determined to have a Serious Mental Illness (SMI), children, pregnant substance abusing women/teenagers, or any person determined to be at risk of relapse, decompensation, deterioration or a potential harm to self or others. Further attempts may include contacting the person or person’s legal guardian face to face or contacting natural supports who the recipient has given permission to the provider to contact. If the person appears to meet clinical standards as a danger to self, danger to others, persistently and acutely disabled or gravely disabled the provider must determine whether it is appropriate, and make attempts as appropriate, to engage the person to seek inpatient care voluntarily. If this is not a viable option for the person and the clinical standard is met, initiate the pre-petition screening or petition for treatment process described in Section 3.18, Pre-petition Screening, Court Ordered Evaluation and Court Ordered Treatment.

All attempts to re-engage persons determined to have a Serious Mental Illness (SMI), children, pregnant substance abusing women/teenagers, or any person determined to be at risk of relapse, decompensation, deterioration or a potential harm to self or others must be clearly documented in the comprehensive clinical record.

Follow-up after significant and/or critical events
Behavioral health providers must also document activities in the clinical record and conduct follow-up activities to maintain engagement within the following timeframes:

  • Discharged from inpatient services in accordance with the discharge plan within 7 days, or no later than 30 days;
  • Involved in a behavioral health crisis within timeframes based upon the person’s clinical needs, but no later than 7 days;
  • Refusing prescribed psychotropic medications within timeframes based upon the person’s clinical needs and individual history; and
  • Released from local and county jails and detention facilities within 72 hours.

Additionally, for persons to be released from Level I care, behavioral health providers must help establish priority prescribing clinician appointments within 7 days of the person’s release to ensure client stabilization, medication adherence, and to avoid re-hospitalization.

All Level I hospitals and residential treatment centers must fax a Med Sheet and Diagnosis to 602-528-1341 or send via a secure (HIPAA compliant, encrypted) email at time of discharge for all Gila River members. Receipt of this information is a prerequisite to obtaining a follow up psychiatric appointment with a Gila River behavioral health medical practitioner.

Go to top

3.8.3-D: Ending an Episode of Care for a person in the behavioral health system
Under certain circumstances, it may be appropriate or necessary to disenroll a person or end an episode of care from services after re-engagement efforts described in section 3.8.3-C have been expended. Ending the episode of care can occur due to clinical or administrative factors involving the enrolled person. The episode of care can be ended for both NTXIX and TXIX individuals, but TXIX eligible individuals no longer in an episode of care for behavioral health services remain enrolled with AHCCCS. When a person is disenrolled or has an episode of care ended, notice and appeal requirements may apply (see Section 5.1, Notice Requirements and Appeal Process for Title XIX and Title XXI Eligible Persons and Section 5.5, Notice and Appeal Requirements (SMI and Non-SMI/Non-Title XIX/XXI.)

Clinical Factors

  • Treatment Completed:
    Person's episode of care must be ended upon completion of treatment. A NTXIX person would also be disenrolled at treatment completion. Prior to ending the episode of care or disenrolling a person following the completion of treatment, the behavioral health provider and the person or the person’s legal guardian must mutually agree that behavioral health services are no longer needed.
  • Further Treatment Declined:
    A person's episode of care must be ended if the person or the person’s legal guardian decides to refuse ongoing behavioral health services. A NTXIX person would also be disenrolled from services. Prior to ending the episode of care or disenrolling a person for declining further treatment, the behavioral health provider must ensure the following:
    • All applicable and required re-engagement activities described in subsection 3.8.3-C. have been conducted and clearly documented in the person's comprehensive clinical record; and
    • The person does not meet clinical standards for initiating the pre-petition screening or petition for treatment process described in Section 3.18, Pre-petition Screening, Court Ordered Evaluation and Court Ordered Treatment.
    • Upon receiving a request from a CPS case manager or representative to discontinue services and/or disenroll a foster child, the behavioral health provider will conduct a Child Family Team (CFT) staffing to determine if this is clinically sound.
  • Lack of Contact:
    A person’s episode of care may be ended if the T/RBHA or behavioral health provider is unable to locate or make contact with the person after ensuring that all applicable and required re-engagement activities described in subsection 3.8.7-C have been conducted. A NTXIX individual would also be disenrolled from services.

Administrative Factors

Eligibility/entitlement information changes including:

  • Loss of Title XIX/XXI eligibility, if other funding is not available to continue services; and
  • Persons who become or are enrolled as elderly or physically disabled (EPD) under the Arizona Long Term Care System (ALTCS) must be disenrolled from the T/RBHA after ensuring appropriate coordination and continuity of care with the ALTCS program contractor. (Not applicable for developmentally delayed ALTCS members (ALTCS/DD) whose behavioral health treatment is provided through the T/RBHA system.) An ALTCS/EPD eligible person may remain enrolled with the T/RBHA as Non-Title XIX if the person has been determined to have a serious mental illness (SMI) and will continue to receive Non-Title XIX covered SMI services through the T/RBHA.

Behavioral health providers may disenroll Non-Title XIX/XXI eligible persons for non-payment of assessed co-payments per Section 3.4, Co-payments, under the following conditions:

  • The person is not eligible as a person determined to have a Serious Mental Illness (SMI) per Section 3.10, SMI Eligibility Determination; and
  • Attempts at reasonable options to resolve the situation, (e.g., informal discussions) do not result in resolution. All efforts to resolve the issue must be documented in the person's comprehensive clinical record, in accordance with Section 3.4, Co-Payments.

Out-of-State Relocations

  • A person's episode of care must be ended for a person who relocates out-of-state after appropriate transition of care. A NTXIX individual would also be disenrolled. This does not apply to persons placed out-of-state for purposes of providing behavioral health treatment (see Section 3.22, Out-of-State Placements for Children and Young Adults).

Inter-T/RBHA Transfers

  • A person who relocates to another T/RBHA and requires ongoing behavioral health services must be closed from one T/RBHA and transferred to the new T/RBHA. Services must be transitioned per Section 3.17, Transition of Persons.

Arizona Department of Corrections Confinements
A person age 18 or older must be disenrolled upon acknowledgement that the person has been placed in the long-term control and custody of a correctional facility.

Children Held at County Detention Facilities

  • A child who was served by a T/RBHA prior to detainment in a county detention facility will remain in an episode of care as long as the child remains Title XIX/XXI eligible. T/RBHAs and/or their subcontracted providers must check the AHCCCS Pre-paid Medical Management Information System (PMMIS) to ensure Title XIX/XXI eligibility prior to the delivery of each behavioral health service to a child who is held in a county detention facility. (See additional information in the ADHS/DBHS Practice Protocol, Providing Services to Children in Detention).

Inmates of public institutions

  • AHCCCS has implemented an electronic inmate of public institution notification system developed by the AHCCCS Division of Member Services (DMS). If a member is eligible for AHCCCS covered services during the service delivery period, T/RBHAs are obligated to cover the services regardless of the perception of the member’s legal status.
  • In order for AHCCCS to monitor any change in a member’s legal status, and to determine eligibility, T/RBHAs and their subcontracted providers will need to notify AHCCCS via e-mail, and if they become aware that an AHCCCS eligible member is incarcerated. AHCCCS has established email addresses for this purpose. Please note that there are two separate e-mail addresses based on the member’s age. For children less than 18 years of age, please use DMSJUVENILEincarceration@azahcccs.gov. For adults age 18 years and older, please use DMSADULTIncarceration@azahcccs.gov. Notifications must include the following member information:
    • AHCCCS ID;
    • Name;
    • Date of Birth;
    • Incarceration date; and
    • Name of public institution where incarcerated.

    Please note that Providers do not need to report members incarcerated with the Arizona Department of Corrections.

Deceased Persons

  • A person's episode of care must be ended following acknowledgement that the person is deceased, effective on the date of the death. The NTXIX individual would be disenrolled from the system.

Crisis Episodes
For persons who are enrolled as a result of a crisis episode, the person's episode of care would end if the following conditions have been met:

  • The behavioral health provider conducts all applicable and required re-engagement activities described in subsection 3.8.3-C and such attempts are unsuccessful;
  • The behavioral health provider and the person or the person’s legal guardian mutually agree that ongoing behavioral health services are not needed;
  • A NTXIX individual would be disenrolled from the system.

One Time Consultations
For persons who are in the system for the purpose of a one time consultation as described in Section 4.3, Coordination of Care with AHCCCS Health Plans, Primary Care Providers, and Medicare Providers, the person's episode of care may be ended if the behavioral health provider and the person or the person’s legal guardian mutually agree that ongoing behavioral health services are not needed. The NTXIX individual would also be disenrolled.

Data Submission
Behavioral health providers must follow all applicable data submission procedures as described in Section 7.5, Enrollment, Disenrollment and Other Data Submission and the ADHS/DBHS Demographic and Outcome Data Set User Guide following a decision to end an episode of care or disenroll.

Providers within the Gila River RBHA network are not responsible for the submission of 834-enrollment and disenrollment data transactions. The Gila River RBHA completes all such transactions and submits data directly to ADHS.

Go to top

3.8.3-E: Serving a person previously enrolled in the behavioral health system
Some persons who have ended their episode of care or were disenrolled may need to re-enter the behavioral health system. The process used is based on the length of time that a person has been out of the behavioral health system.

For persons not receiving services
for less than 6 months
For persons not receiving services
for 6 months or longer

If the person has not received a behavioral health assessment in the past 6 months, conduct a new behavioral health assessment consistent with Section 3.9, Intake, Assessment and Service Planning, and revise the person’s service plan as needed.

If the person has received a behavioral health assessment in the last six months and there has not been a significant change in the person’s behavioral health condition, T/RBHAs or behavioral health providers may utilize the most current assessment. Review the most recent service plan (developed within the last six months) with the person, and if needed, coordinate the development of a revised service plan with the person’s clinical team (see Section 3.9, Intake, Assessment and Service Planning).

Conduct a new intake, behavioral health assessment and service plan consistent with Section 3.9, Intake, Assessment and Service Planning.
Continue the person’s SMI status if the person was previously determined to have a Serious Mental Illness (SMI) (see Section 3.10, SMI Eligibility Determination). Continue the person’s SMI status if the person was previously determined to have a Serious Mental Illness (SMI) (see Section 3.10, SMI Eligibility Determination).
If the person presents at a different T/RBHA or provider, obtain new general and informed consent to treatment (see Section 3.11, General and Informed Consent to Treatment). Obtain new general and informed consent to treatment, as applicable (see Section 3.11, General and Informed Consent to Treatment).
If the person presents at a different T/RBHA or provider, obtain new authorizations to disclose confidential information, as applicable (see Section 4.1, Disclosure of Behavioral Health Information). Obtain new authorizations to disclose confidential information, as applicable (see Section 4.1, Disclosure of Behavioral Health Information).
Submit new demographic and enrollment data (see Section 7.5, Enrollment, Disenrollment and Other Data Submission). Submit new demographic and enrollment data (see Section 7.5, Enrollment, Disenrollment and Other Data Submission).

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

3.8 Outreach, Engagement, Re-engagement, and Ending an Episode of Care and Disenrollment
Last Revised: 12/20/2013
Effective Date: 12/20/2013

Gila River Health Care Corporation address and phone