COMMUNICATION MEMO # 356 TO

24 Hour Access to Care and Crisis Services 1-866-875-1757
Information, Questions, Concerns or Complaints 1-855-250-1539
COMMUNICATION MEMO # 356
TO:
COASTALCARE PROVIDER NETWORK
FROM:
William Holtz, Network Management Director
Kristy Maddox Reed, Network Liasion Manager
SUBJECT:
Update to Guidelines for First Responder Responsibilities
DATE:
May 9, 2014
This guidance was developed by the CoastalCare Clinical Advisory Committee, composed of innetwork licensed clinicians and CoastalCare clinical staff. Additional clarification information
has been added to Outpatient Services and Innovations Services.
CoastalCare and its’ community partners have established the goal of reducing the use of
Emergency Departments for the management of behavioral health crises. Mental health
practitioners have been charged with the shared responsibility of treating consumers in the
least restrictive level of care. For most services, it is imperative that each consumer’s crisis plan
be comprehensive and current with CoastalCare and the primary care provider, as Mobile Crisis
Services will have access to these plans when responding to crises. Additionally, Crisis Plans are
to be developed in the presence of the consumer and their supports and should clearly state
that the first step in a crisis is to call the First Responder. CoastalCare and its Clinical Advisory
Committee have provided the guidelines below to address expectations regarding First
Responder duties.
Enhanced MH/IDD/SU services
The MH/SU services ACTT, MST and IIH require telephonic and face to face first responders and
they must be from the specific team serving the consumer. Enhanced services that require first
responders must follow the established guidelines of telephonic response within 15 minutes
and face to face response within 2 hours when clinically indicated. If a consumer presents in a
crisis facility (Facility-Based Crisis, ED, etc.), the first responder is expected to provide
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consultation with the facility and provide face to face support (for ACTT, MST and IIH) if
clinically indicated or upon request of the crisis facility.
All other enhanced services require 24 hour telephonic response to crisis calls. If reasonable
efforts to de-escalate the crisis have been unsuccessful and a face to face response is indicated,
mobile crisis can be contacted for this response. This will ensure that crisis services can be
monitored and streamlined in the CoastalCare catchment area. The direct number for Mobile
Crisis is 1-855-345-1200.
Outpatient Services
In accordance with Clinical Coverage Policy 8C, all outpatient enrolled providers and
practitioners shall provide, or have a written agreement with another entity, for access to 24hour coverage for behavioral health emergency services. CoastalCare’s expectation is that
when an individual who is receiving outpatient services and is currently enrolled in Medicaid or
receives state funded services, has a behavioral health crisis that the practitioner or entity with
whom they have an agreement to provide crisis services, will respond as soon as possible, but
no longer than two hours after receiving a call. If reasonable efforts to de-escalate the crisis
have been unsuccessful and a face to face response is indicated, mobile crisis can be contacted
for this response. This will ensure that crisis services can be monitored and streamlined in the
CoastalCare catchment area. The direct number for Mobile Crisis is 1-855-345-1200.
If independent practitioners are serving consumers on an outpatient basis who have a history
of crisis episodes, have stepped down from enhanced services or demonstrate other clinical risk
factors, the practitioner may use the attached crisis plan or comprehensive crisis plan to
augment the outpatient treatment plan. If you elect to use one of these crisis plans, please
submit the plan to CoastalCare for purposes of continuity of care and implementation by the
crisis services providers.
PCP with built in Crisis Plan
Crisis Prevention and Intervention Plan (Pages 3 and 4 of PCP)
Communication Bulletin #139: Person-Centered Crisis Prevention & Intervention Plan & Crisis
Plan Training Element
Innovations Services
The 1915(c) Waiver service, “Crisis Primary Response” include trained staff to provide “first
response” crisis services to Innovations waiver participants they support, in the event of a crisis
including assessing the nature of the crisis for stabilization or linkage to higher levels of
intervention, intervention to deescalate the crisis and maintain safety, contact and
collaboration with the assigned care coordinator, and provision of education and training
pertaining to interventions that aid in managing the crisis with other providers supporting the
waiver participant. Providers will respond to emergencies of participants and have a back-up
system in place to respond to emergencies/crises on weekends and evenings as outlined in the
NC Innovations Service Definitions. Providers of In-Home Intensive Supports, In-Home Skill
Building, Personal Care and Residential Support services are required to have QP staff available
as Primary Crisis Services providers for emergencies that occur with participants in their care 24
hours per day 7 days per week or have an arrangement (memorandum of understanding) with
a Primary Crisis Services Provider. The beneficiary, however, may select any enrolled Crisis
Services provider in lieu of this provider.
Personal Care
Employers of Record have an arrangement with an enrolled crisis services provider to respond
to participant crisis situations. Agency with Choice provides or maintains an agreement with a
Crisis Service Provider to respond to participant crisis situations. The participant, however, may
select any enrolled Crisis Services provider in lieu of this provider.
In Home Skill Building
Provider has an arrangement with an enrolled crisis services provider to respond to participant
crisis situations. Agency with Choice provides or has an arrangement with an enrolled Crisis
Service Provider to respond to participant crisis situations. The participant, however, may select
any enrolled Crisis Services provider in lieu of this provider.
In Home Intensive Supports
Providers are enrolled to provide Crisis Services or arrangement with an enrolled Crisis Services
Provider to respond to participant crisis situations. The participant, however, may select any
enrolled Crisis Services provider in lieu of this provider.
Residential Supports
Providers are enrolled to provide Crisis Services or have an arrangement with an enrolled Crisis
Services Provider to respond to participant crisis situations. The Participant, however, may
select any enrolled Crisis Services provider in lieu of this provider.
The 1915(c) Innovations waiver service, “Residential Support Levels I-IV,” have first responder
responsibilities for the 24 hour residential service delivery. Individuals receiving Residential
Supports may also access Primary Response services within utilization limit. Crisis Services
within the Innovations waiver include a tiered approach to support waiver recipients that also
may include Out of Home Crisis Respite for a short term period of structured support and
programming in a licensed Crisis respite facility as an alternative to institutional placement or
psychiatric hospitalization. Additionally, the tiered approach Crisis Behavioral Consultation is
available to participants that have intensive, significant, challenging behaviors that have
resulted in a crisis situation requiring the development of a formal crisis support plan. Primary
response services include trained staff to provide “first response” crisis services to innovation
waiver participants as an add-on service.
Residential Services
Residential services for Individuals with Developmental Disabilities also include face to face first
responder responsibilities for the 24 hour residential service delivery.
The 1915(b) Waiver service, “Intermediate Care Facilities for Individuals with Intellectual
Disabilities (ICF-IDD0 residential,” have first responder 24 hour coverage requirements for their
inclusive service per N.C. Division of Medical Assistance Clinical Coverage Policy 8E.
Therapeutic Foster Care and Level III residential services have QP level staff that should respond
to consumer crises, to support direct care staff, stabilize the crisis and determine clinically
appropriate follow up. As an alternative to using the Emergency Department, Mobile Crisis
Management can be used to address circumstances involving consumer safety.
Non-Compliant Consumers
CoastalCare cannot force agencies to see clients against their will. However, it is the goal and
the expectation of CoastalCare that providers not abandon difficult clients. Therefore, in order
to discharge clients who choose not to engage in services or choose not to engage in the
recommended level of care, providers must maintain documentation of a good faith effort to
engage clients. It is expected that documentation will include phone calls to clients, letters
requesting engagement, and in the case of a missing client, at minimum an emergency contact
be called.
If these efforts fail, it must be documented that a letter or phone call notifying the client of
discharge was completed whenever permission was given to communicate via letter or phone
call. It will be the standard that a minimum of a 30 day notice is given to allow the client time to
respond and for the provider to be available in case of an emergency. After the designated
time identified in the discharge letter/phone message has lapsed, the case must be reviewed
with a supervisor including the level of risk of the client at the time of discharge. The decision to
discharge must be reviewed and signed by a supervisor.
If the treating psychiatrist is at the agency that is completing the discharge, it is recommended
that a thirty day medication bridge be offered to the client (at the time of the 30 day
notification of discharge) whenever possible and/or appropriate to allow for transition to a new
prescriber.
The exception to this is for individuals with developmental disabilities residing in licensed
residential facilities where state continuity of care laws requires a 60 day discharge notice in
writing.
Retaining Medication Management Only clients when a higher level of care is recommended
The CoastalCare benefit plan clearly states level of care needs and requirements for
reimbursement and this should be followed when determining level of risk. The level of care of
medication management only must be recommended for this service to be provided without
any other services. If a client refuses a higher level of care and requests medication
management only, the provider can gauge the risk for following this plan of care and determine
if it is appropriate. The provider then has the choice to maintain the client on medication
management only for engagement/further assessment or to inform the client of the risks of not
engaging in the recommended level of care and thus the need for discharge after 30 days of
being available for emergency response. If the Physician chooses to continue with Medication
Management only and the client displays a high level of risk, there must be evidence that
someone else in the agency is following the client’s progress. If consumer meets the criteria of
Care Coordination, a Care Coordinator will link consumer to services again and monitor until
consumer is engaged in treatment.

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