Behavioral Health Rehabilitation Services Transitioning to Intensive Behavioral Health Services (IBHS) – Part Two of PHLP’s Summary of Changes
As highlighted in our October newsletter, the state made significant changes to rules governing the delivery mental health services to children and adolescents. The Pennsylvania Office of Mental Health and Substance Abuse Services (OMHSAS) has established new regulations for Intensive Behavioral Health Services (IBHS) to replace Behavioral Health Rehabilitation Services (BHRS) for the delivery of child and adolescent services in the home, school, and community. The new regulations (Title 55, Chapters 1155 and 5240) become effective on January 17, 2020.
IBHS support children, youth, and young adults with mental, emotional, and behavioral health needs. IBHS offers an array of services that can meet the needs of these individuals in their homes, schools, and communities. There are three categories of service: 1) Individual services which provide services to one child; 2) Applied Behavior Analysis (ABA) which is a specific behavioral approach to services; and 3) Group services which are most often provided to multiple children at a specific place. The changes include increased requirements for staff training, supervision, and credentialing. These new regulations were built from needs identified, during a years-long process, by community stakeholders (including school district principals, provider agencies, and consumers) during targeted focused groups for improved access and quality of care for children, youth, and young adults.
In our October newsletter, we detailed the changes to Applied Behavioral Analysis with IBHS. In this article we describe the two other categories of IBHS services: 1) Individual Services for one child and 2) Group Services provided to multiple children at a specific place.
Individual Services
Individual Services are provided one-to-one to children, youth, and young adults (under age 21) (hereafter referred to as youth) with mental, emotional, and behavioral health needs. These services can be provided with Behavior Consultation (BC) Services, Mobile Therapy (MT) Services and/or Behavioral Health Technician (BHT) Services. BC services include an assessment of the youth’s behavioral needs, development of an Individual Treatment Plan (ITP) which includes interventions to be used and when and where they occur. The youth’s ITP should be developed with the youth (as appropriate), family members, and other providers and school personnel as indicated. BC services can be provided in the home, school, or other community settings based on the needs of the youth. BC services replace BSC (Behavior Specialist Consultant) that were a part of BHRS.
Mobile Therapy (MT) services can also include an assessment and development of the ITP, if not already done by a BC. MT can include individual therapy, family therapy, assistance with crisis stabilization, and assistance with other problems encountered by the youth and/or family. MT services are similar to the MT services that were a part of BHRS.
BHT services are used to implement the youth’s ITP. BHT services replace TSS (Therapeutic Staff Support) services that were a part of BHRS.
Group Services
Group services are intensive therapeutic interventions that are provided in a group format. They can be provided in school or community settings such as a daycare or afterschool program. Group services include group and family psychotherapy, design of psychoeducational group activities, clinical direction of group services, creation and revision of the ITP, and oversight of the ITP implementation and consultation with the treatment team. IBHS regulations do not include a staff to client ratio for group services but providers of group services must identify that ratio in their service description to OMHSAS. Parent-Child Interaction Therapy (PCIT) can be provided as a group service. Examples of group services include Group Applied Behavior Analysis, School-Based Programs, After-School Programs, and Summer Therapeutic Activities Programs.
How to Obtain Individual and Group Services under Medical Assistance
Written Order (i.e., Prescription)
The process begins with a written order. Professionals qualified to do a written order include a physician, licensed psychologist, certified registered nurse practitioner, physician assistant, licensed social worker, licensed professional counselor, and licensed family therapist. The written order must be based on a face-to-face interaction with the youth. PLEASE NOTE: In our October newsletter we stated a face to face interaction is not required for the written order – that is incorrect and we apologize for that error. The order must be written within 12 months of initiation of services. The initiation of services is the first day an individual service or group service is provided.
The written order must include:
a behavioral health disorder diagnosis listed in the most recent edition of the DSM or ICD; or
one or more orders for IBHS for the youth and includes the following:
(a) The clinical information to support the medical necessity of the service ordered.
(b) The maximum number of hours of each service per month.
(c) The settings where services may be provided.
(d) The measurable improvements in the identified therapeutic needs that indicate when services may be reduced, changed, or terminated.
The Assessment
Once the youth has a written order for services, an assessment must be completed, in the home or community-based setting. The qualifications of the professional administering the assessment depend on the service prescribed. An individual qualified to provide behavior consultation services or mobile therapy services must complete an assessment for individual services. A graduate-level professional must complete an assessment for group services.
The assessment must provide information on the youth and family’s strengths, existing and needed supports, and clinical information that includes the following:
(i) Treatment history.
(ii) Medical history.
(iii) Developmental history.
(iv) Family structure and history.
(v) Educational history.
(vi) Social history.
(vii) Trauma history.
(viii) Other relevant clinical information.
The assessment must also include the youth's level of developmental, cognitive, communicative, social, and behavioral functioning across the home, school, and other community settings. The cultural, language, or communication needs and preferences of the youth and the parent, legal guardian, or caregiver should also be included in the assessment.
The assessment provides specifics for what services are needed, in what setting, and in what amount. If the assessment indicates the youth needs more services than the maximum indicated in the written order, the assessor and the prescriber should discuss why. For the youth to receive more services than indicated in the written order, a new written order must be done.
Individual Treatment Plan (ITP)
An individual treatment plan must be developed from the information in the written order and assessment within 30 days of the initiation of individual services or group services. (Please note from our October newsletter that the ITP timeframe for ABA services is 45 days). An ITP for individual services is a detailed written plan of treatment services specifically tailored to address a youth's therapeutic needs that contains the type, amount, frequency, setting and duration of services to be provided and the specific goals, objectives and interventions for the service.
For Individual Services, the ITP must be developed in collaboration with the youth’s parent, legal guardian, or caregiver as appropriate and include:
(1) Service type and the number of hours of each service.
(2) Whether and how parent, legal guardian, or caregiver participation is needed to achieve the identified goals and objectives.
(3) Safety plan to prevent a crisis, a crisis intervention plan, and a transition plan.
(4) Specific goals, objectives, and interventions to address the identified therapeutic needs with definable and measurable outcomes.
(5) Time frames to complete each goal.
(6) Settings where services may be provided.
(7) Number of hours of service at each setting.
For Group Services: The ITP must be developed with the youth and parent, legal guardian, or caretaker as appropriate and include the following:
(1) Specific goals and objectives to address the identified therapeutic needs with definable and measurable outcomes.
(2) Whether and how parent, legal guardian, or caregiver participation is needed to achieve the identified goals and objectives.
(3) Structured therapeutic activities, community integration activities, and individual interventions to address identified therapeutic needs for the child, youth, or young adult to function at home, school, or in the community.
(4) Time frames to complete each goal.
(5) Settings where group services may be provided.
(6) Number of hours that group services will be provided to the child, youth, or young adult.
For Individual Services and Group Services, the ITP shall be reviewed and updated at least every 6 months or if one of the following occurs:
(1) The child, youth, or young adult has made sufficient progress to require that the ITP be updated.
(2) The child, youth, or young adult has not made significant progress towards the goals identified in the ITP within 90 days from the initiation of the services.
(3) The youth or young adult requests an update.
(4) A parent, legal guardian, or caregiver of the child or youth requests an update.
(5) The child, youth, or young adult experiences a crisis event.
(6) The ITP is no longer clinically appropriate for the child, youth or young adult.
(7) A staff person, primary care physician, other treating clinician, case manager, or other professional involved in the child's, youth's, or young adult's services provides a reason an update is needed.
(8) The child, youth, or young adult experiences a change in living situation that results in a change of the child's, youth's, or young adult's primary caregivers.
Evidenced Based Therapies (EBT) can be provided through Individual Services and Group Services. EBT are behavioral health interventions that use scientifically established methods. More of EBT can be found in the state’s Family Fact Sheet and in the IBHS regulations.
For youth currently receiving BHRS, providers will work with families as they transition to IBHS. OMHSAS is committed to no disruption in services for those youth now receiving BHRS. Families who experience BHRS service disruptions should contact their Medicaid Behavioral Health Managed Care plan or call PHLP’s Helpline at 1-800-274-3258.
