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 4.4 Coordination of Care with Other Government Entities

4.4.1 Introduction
4.4.2 Terms
4.4.3 Procedures
4.4.3-A. Arizona Department of Economic Security/Division of Children, Youth and Families (ADES/DCYF)
4.4.3-B. Arizona Department of Education (ADE), Schools or Other Local Educational Authorities
4.4.3-C. Arizona Department of Economic Security/Division of Developmental Disabilities (ADES/DDD)
4.4.3-D. Arizona Department of Economic Security/Arizona Early Intervention Program (ADES/AzEIP)
4.4.3-E. Courts and Corrections
4.4.3-F. Arizona County Jails
4.4.3-G. Arizona Department of Economic Security/Rehabilitation Services Administration (ADES/RSA)
4.4.3-H. Arizona Department of Health Services/Office of Assisted Living Licensure
4.4.4 References 

4.4.1 Introduction
Effective communication and coordination of services are fundamental objectives for providers when serving recipients involved with other government entities. When providers and public service providers coordinate care efficiently, the following positive outcomes can occur:

  • Duplicative and redundant activities, such as assessments, service plans and agency meetings are minimized;
  • Continuity and consistency of care are achieved;
  • Clear lines of responsibility, communication, and accountability across service providers in meeting the needs of the recipient and family are established and communicated; and
  • Limited resources are effectively utilized.

The Arizona Department of Health Services/Division of Behavioral Health Services (ADHS/DBHS) recognizes the importance of a responsive behavioral health system, especially when the needs of vulnerable recipients have been identified by other government entities. For example, ADHS/DBHS strongly supports the timely response and coordination of services for children who have been, or imminently will be, removed from their homes by the Arizona Department of Economic Security/Child Protective Services (ADES/CPS) (see Section 3.2, Appointment Standards and Timeliness of Service). ADHS/DBHS expects all providers to collaborate and provide any necessary assistance when CPS initiates requests for covered services or supports.

The intent of this section is to communicate the ADHS/DBHS expectation that behavioral health providers cooperate and actively work with other agencies serving recipients.

ADHS/DBHS has Intergovernmental Agreements (IGAs), Interagency Service Agreements (ISAs) and Memorandums of Understanding (MOUs) with several State, county, Tribal and local agencies to collaborate while serving persons involved with multiple systems.

ADHS/DBHS has developed a Practice Protocol, Child and Family Team Practice. The protocol includes suggested guidelines for developing and maintaining a collaborative relationship with other government entities that deliver services to children.

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4.4.2 Terms
Adult Clinical Team

Child and Family Team (CFT)

Individualized Education Program (IEP)

State Placing Agencies

4.4.3 Procedures

4.4.3-A: Arizona Department of Economic Security/Division of Children, Youth and Families (ADES/DCYF)
When a child receiving behavioral health services is also receiving services from ADES/DCYF, the provider works towards effective coordination of services by working in collaboration with the CPS Specialist. Providers are expected to:

  • Coordinate the development of the behavioral health service plan with the child welfare case plan to avoid redundancies and/or inconsistencies;
  • Ensure an urgent response to DCYF initiated referrals for children who have been removed from their homes (see Section 3.2, Appointment Standards and Timeliness of Service);
  • Provide the CPS Specialist and the juvenile court with preliminary findings and recommendations on behavioral health risk factors, symptoms and service needs for consideration in the development of the child’s CPS case plan for the initial preliminary protective hearing;
  • Work collaboratively on child placement decisions if placement and funding are being sought for behavioral health treatment;
  • Invite the CPS Specialist, CPS providers and resource parents to participate in the behavioral health assessment and service planning process as members of the Child and Family Team (CFT) (see Section 3.9, Assessment and Service Planning);
  • Strive to be consistent with the service goals established by other agencies serving the child or family. Behavioral health service plans must be directed by the CFT toward the behavioral health needs of the child, and the team should seek the active participation of other involved agencies in the planning process.
  • Attend team meetings such as Team Decision Making (TDM) and Family Group Decisions (as appropriate) for the purpose of providing input about the child and family’s health needs. Where it is possible, TDM and CFT meetings should be combined.
  • Coordinate, communicate and expedite necessary services to stabilize in-home and out-of-home placements provided by DCYF;
  • Provide behavioral health services during the reunification process and/or other permanency plan options facilitated by DCYF. Parent-child visitation arrangements and supervision are the responsibility of CPS. Therapeutic visitation is not a covered behavioral health service.; and
  • Ensure responsive coordination activities and service delivery that supports DCYF planning and facilitates adherence to DCYF established timeframes (see Practice Protocol, The Unique Behavioral Health Service Needs of Children, Youth, and Families Involved with CPS) and Practice Protocol, Transition to Adulthood.

ADES/ADHS Arizona Families F.I.R.S.T. (Families in Recovery Succeeding Together) Program
Behavioral health providers must ensure coordination for parents/families referred through the Arizona Families F.I.R.S.T (AFF) program (see Attachment 4.4.2, Arizona Families F.I.R.S.T. (AFF) Program Model and Referral Process).

The AFF program provides expedited access to substance abuse treatment for parent and caregivers referred by ADES/CDCYF/DPS and the ADES/FAA Jobs Program. ADHS/DBHS participates in statewide implementation of the program with ADES (see A.R.S. 8-8881). T/RBHAs and providers must:

  • Accept referrals for Title XIX and Title XXI eligible and enrolled recipients and families referred through AFF;
  • Accept referrals for Non-Title XIX and Non-Title XXI persons and families referred through AFF and provide services, if eligible (see Section 3.19,Special Populations and Section 3.21, Service Package for Non-Title XIX/XXI Persons Determined to have a Serious Mental Illness (SMI)).
  • Ensure that services made available to persons who are Non-Title XIX and Non-Title XXI eligible are provided by maximizing available federal funds before expending state funding as required in the Governor’s Executive Order 2008-01;
  • Collaborate with ADES/DCYF/CPS, ADES/FAA JOBS Program and Substance Abuse Treatment providers to minimize duplication of assessments and achieve positive outcomes for families; and
  • Develop procedures for collaboration in the referral process to ensure effective service delivery through the T/RBHA behavioral health system. Appropriate authorizations to release information must be obtained prior to releasing information.

Due to tribal sovereignty, ADES/DCYF has no jurisdiction on Arizona Indian reservations. Tribal Social Services (TSS) is the child welfare agency responsible for serving residents and members of the Gila River Indian Community. The Gila River RBHA expedites referrals from TSS for children who have been removed from their home or are at imminent risk for removal. The Gila River RBHA and subcontracted behavioral health providers coordinate closely with TSS caseworkers through clinical staffings and joint treatment planning to enhance child safety and maximize treatment effectiveness.

The goal of the AFF Program is to promote permanency for children, stability for families, protect the health and safety of abused and/or neglected children and promote economic security for families. Substance abuse treatment to families involved with DES/DCYF/CPS must be family centered, provide for sufficient support services and provided in a timely manner (see Section 3.2. Appointment Standards and Timeliness of Service, 3.2.7-G, Special Populations).

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4.4.3-B: Arizona Department of Education (ADE), Schools or Other Local Educational Authorities
ADHS/DBHS has delegated the functions and responsibilities as a State Placing Agency to the T/RBHAs. As such it is the expectation of ADHS/DBHS that RBHAs work in collaboration with the ADE for the placement of children with behavioral health service providers.

Behavioral health providers serving children can gain valuable insight into an important and substantial element of a child’s life by soliciting input from school staff and teachers. Behavioral health providers can collaborate with schools and help a child achieve success in school by:

  • Working in collaboration with the school and sharing information to the extent permitted by law and authorized by the child’s parent or legal guardian (see Section 4.1, Disclosure of Behavioral Health Information);
  • For children receiving special education services, actively consider information and recommendations contained in the IEP in the ongoing assessment and service planning process (see Section 3.9, Assessment and Service Planning);
  • For children receiving special education services, ensuring that the behavioral health provider or designee participates with the school in developing the child’s (IEP) and share the behavior treatment plan interventions, if applicable;
  • Inviting teachers and other important school staff to participate in the child and family team if agreed to by the child and legal guardian;
  • Having clear understanding of the IEP requirements as described in the Individuals with Disabilities Education Act (IDEA) of 2004;
  • Ensuring that students with disabilities who qualify for accommodations under Section 504 of the Rehabilitation Act of 1973 are provided adjustments in the academic requirements and expectations necessary to accommodate their needs and enable them to participate in the general education program; and
  • Ensuring that transitional planning occurs prior to and after discharge of an enrolled child from any out-of-home placement.

The Gila River RBHA and subcontracted providers collaborate with on-reservation public schools as well as schools funded through the Bureau of Indian Affairs (BIA).

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4.4.3-C. Arizona Department of Economic Security/Division of Developmental Disabilities (ADES/DDD)
Persons qualifying for services through DDD can fall into several different categories based on their eligibility status and the extent of their disability. There are three general groupings:

Type of DDD Eligibility What behavioral health services are available? Who is responsible for providing the behavioral health services?
Title XIX and eligible for ALTCS All Title XIX covered services T/RBHAs and contracted providers
Title XIX and not eligible for ALTCS All Title XIX covered services T/RBHAs and contracted providers
Non-Title XIX Services provided based on eligibility for services* T/RBHAs and contracted providers based on eligibility for services*
*
See Section 3.19, Special Populations.

Behavioral health providers strive towards effective coordination of services with recipients receiving services through DDD by:

  • Working in collaboration with DDD staff and service providers involved with the recipient;
  • Providing assistance to DDD providers in managing difficult behaviors:
  • Inviting DDD staff to participate in the development of the behavioral health service plan and all subsequent planning meetings as members of the recipient’s clinical team (see Section 3.9, Assessment and Service Planning);
  • Incorporating information and recommendations in the Individual or Family Support Plan (ISP) developed by DDD staff, when appropriate, while developing the person’s ISP;
  • Ensuring that the goals of the ISP of a recipient diagnosed with developmental disabilities who is receiving psychotropic medications includes reducing behavioral health symptoms and achieving optimal functioning, not merely the management and control of behavior;
  • Actively participating in DDD team meetings; and
  • For recipients diagnosed with Pervasive Developmental Disorders and Developmental Disabilities, sharing all relevant information, from the initial assessment and ISP with DDD to ensure coordination of services.

For DDD recipients with a co-occurring behavioral health condition or physical health condition who demonstrate inappropriate sexual behaviors and/or aggressive behaviors, a Community Collaborative Care Team (CCCT) may be developed. The CCCT will consist of experts from multiple agencies involved in coordinating care for DDD members who have been unresponsive to traditional ALTCS and Behavioral Health services For additional information regarding the roles and responsibilities of the CCCT and coordination of care expectations, please see the AHCCCS Medical Policy Manual (AMPM), Policy 570, Community Collaborative Care Teams.

Although the RBHAs are capitated to serve all Title XIX persons who are DDD ALTCS eligible, the Gila River RBHA serves a small number of DDD ALTCS members as a courtesy to the capitated behavioral health system. The Gila River RBHA and subcontracted providers refer children identified with possible developmental delays to the Arizona Early Intervention Program and coordinate with the AzEIP team as appropriate.

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4.4.3-D. Arizona Department of Economic Security/Arizona Early Intervention Program (ADES/AzEIP)

Behavioral health service providers can strive toward effective coordination of care for children identified as having, or likely having, disabilities or developmental delays by:

  • Ensuring that children birth to three years of age are referred to AzEIP in a timely manner when information obtained in their behavioral health assessment reflects developmental concerns;

  • Ensuring that children found to require behavioral health services as part of the AzEIP evaluation process receive appropriate and timely service delivery (see Section 3.2, Appointment Standards and Timeliness of Service); and

  • Ensuring that, if an AzEIP team has been formed for the child, the behavioral health provider will coordinate team functions so as to avoid duplicative processes between systems;

  • Coordinating enrollment in the T/RBHA children’s system of care when a child transfers to the children’s DDD system;

4.4.3-E. Courts and Corrections

T/RBHAs and behavioral health providers are expected to collaborate and coordinate care for behavioral health recipients involved with:

  • Arizona Department of Corrections (ADC)
  • Arizona Department of Juvenile Corrections (ADJC)
  • Administrative Offices of the Court (AOC)

When a recipient receiving behavioral health services is also involved with a court or correctional agency, behavioral health providers work towards effective coordination of services by:

  • Working in collaboration with the appropriate staff involved with the recipient
  • Inviting probation or parole recipients to participate in the development of the ISP and all subsequent planning meetings as members of the recipient’s clinical team with recipient's approval;
  • Actively considering information and recommendations contained in probation or parole case plans when developing the ISP; and
  • Ensuring that the behavioral health provider evaluates and participates in transition planning prior to the release of eligible recipients and arranges and coordinates care upon the person’s release (see Section 3.3, Intake and Referral Process).

Behavioral health providers serving Gila River RBHA enrolled members collaborate with the Gila River courts and with the following tribal correctional entities:

Juvenile Department of Rehabilitation and Supervision (JDRS); and
Department of Rehabilitation and Supervision (DRS)

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4.4.3-F. Arizona County Jails
In Maricopa County, when a recipient receiving behavioral health services has been determined to have, or is perceived to have, a Serious Mental Illness (see Section 3.10, SMI Eligibility Determination) and is detained in a Maricopa County jail, the behavioral health provider must assist the recipient by:

  • Working in collaboration with the appropriate staff involved with the recipient;
  • Ensuring that screening and assessment services, medications and other behavioral health needs are provided to jailed recipients upon request;
  • Ensuring that the recipient has a viable discharge plan, that there is continuity of care if the recipient is discharged or incarcerated in another correctional institution and that pertinent information is shared with all staff involved with the recipient’s care or incarceration with recipient approval and in accordance with Section 4.1, Disclosure of Behavioral Health Information; and
  • Determining whether the recipient is eligible for the Jail Diversion Program.

For all other recipients receiving behavioral health services in Maricopa County and all other Arizona counties, behavioral health providers must help ensure that appropriate coordination also occurs for behavioral health recipients with jail personnel at other county jails.

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4.4.3-G. Arizona Department of Economic Security/Rehabilitation Services Administration (ADES/RSA)
The purpose of RSA is to work with individuals with disabilities to achieve increased independence or gainful employment through the provision of comprehensive rehabilitative and employment support services in a partnership with all stakeholders.

Supportive employment services available through the ADHS/DBHS system are distinct from vocational services available through RSA. Please refer to the ADHS/DBHS Covered Behavioral Health Services Guide for more details.

When a recipient determined to have a Serious Mental Illness is receiving behavioral health services and is concurrently receiving services from RSA, the behavioral health provider ensures effective coordination of care by:

  • Working in collaboration with the vocational rehabilitation (VR) counselors or employment specialists in the development and monitoring of the recipient’s employment goals;
  • Ensuring that all related vocational activities are documented in the comprehensive clinical record (see Section 4.2, Behavioral Health Medical Records Standards);
  • Inviting RSA staff to be involved in planning for day programming to ensure that there is coordination and consistency with the delivery of vocational services;
  • Participating and cooperating with RSA in the development and implementation of a Regional Vocational Service Plan; and
  • Allocating space and other resources for VR counselors or employment specialists working with enrolled recipients who have been determined to have a serious mental illness.

Gila River RBHA behavioral health providers collaborate with ADES/RSA local offices throughout Maricopa and Pinal counties to ensure that vocational services are coordinated with the provision of covered behavioral health services.

4.4.3-H. Arizona Department of Health Services/Office of Assisted Living Licensing
When a recipient receiving behavioral health services is also residing in an assisted living facility, behavioral health providers must coordinate with the Office of Assisted Living Licensing to ensure that the facility is licensed and that there are no existing violations or legal orders. Behavioral health providers must also determine and ensure that the recipient living in an assisted living facility is at the appropriate level of care. The behavioral health provider can coordinate with the Office of Assisted Living to determine the level of care that a particular assisted living facility is licensed to provide.

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

4.4 Coordination of Care with Other Government Entities
Last Revised:10/15/2013
Effective Date: 10/15/2013

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