A. Purpose

1. The purpose of these regulations is to comply with R.I. Gen. Laws § 40.1-5-6, which requires any child who is under the age of eighteen whose health insurance is publicly funded to have an emergency service intervention by a provider licensed by the Department of Children Youth and Families (the Department) as a condition for admission to an inpatient psychiatric facility. These regulations set forth the standards for certifying providers and include standards for child and family competent Clinicians.

2. These regulations do not apply to emergency service interventions that result in emergency hospitalizations under R.I. Gen. Laws § 40.1-5-7. This statute provides that when an emergency hospitalization needs to occur, the preauthorization procedure required for authorization by the insurance company may be waived by the certified emergency service provider to protect the safety and well-being of the child and family.

B. Legal Basis

1. These regulations are issued pursuant to:

a. R.I. Gen. Laws § 42-72-5, Power and Scope of Activities of the Department of Children, Youth and Families

b. R.I. Gen. Laws §§ 40.1-5-5. 40.1-5-6 and 40.1-5-8, Mental Health Law

c. R.I. Gen. Laws § 42-72-5.2, Development of a Continuum of Children's Behavioral Health Programs

d. R.I. Gen. Laws § 42-72.1, Licensing and Monitoring of Child Care Providers and Child-Placing Agencies

2. These regulations are consistent with the provisions of Utilization Review of Health Care Services (216-RICR-40-10-20).

3. These regulations include children with Serious Emotional Disturbances (SED) as defined by R.I. Gen. Laws § 42-72-5.

C. Philosophy

1. In accordance with R.I. Gen. Laws § 42-72-5, the Department is responsible for the delivery of appropriate mental health services that match the needs of children.

2. Appropriate behavioral health services may include psychiatric hospitalization, residential treatment and community-based mental health services, including emergency service interventions.

3. The Department has established a service delivery system based on System of Care values to work with families with a child with severe emotional disturbance(s). It is the objective of the Department to develop a culturally and linguistically competent, community based, youth guided and family driven service system, which is responsive to needs and built on strengths.

4. These regulations further reinforce the Department’s values by establishing standards for a child-family competent Clinician (hereinafter, Clinician) who is providing emergency service interventions for children and families. These standards require that the Clinician is knowledgeable of the full range of follow up services and resources including:

a. Community supports and neighborhood resources

b. Community mental health services such as outpatient mental health, intensive outpatient and in-home services

c. In-home supports such as respite and crisis de-escalation

d. Twenty-four hour community-based programs such as shelters, respite, crisis stabilization and acute residential treatment

e. Twenty-four hour Inpatient psychiatric hospitalization

D. Definitions

1. "Child-family competency" means proficiency in clinical practice skills with children with severe emotional disturbance and their families, knowledge of research on child development, application of the knowledge in a clinical context and familiarity and experience with community resources that benefit children and families, including knowledge of the cultural beliefs and practices of the diverse communities served.

2. "Child-family competent clinician" means a Registered Nurse, Masters Level Clinician, licensed Master’s Level Mental Health Clinician, M.D., Ph.D., Ed.D. or Psy.D. Psychologist, Master’s Level Nurse, or Clinical Nurse Specialist. The Child- Family Competent Clinician (hereinafter, Clinician) must have at least two years of clinical experience with children and adolescents who have behavioral health problems. This clinical experience must have been supervised by an independently licensed mental health Clinician. The Clinician must meet the standards of Child-Family Competency as described in the standards below.

a. Each certified Provider must determine the child-family competency of all staff providing children’s emergency services.

3. "Crisis evaluation" means a comprehensive assessment by the Clinician to evaluate the seriousness of the mental health crisis based on the child’s functioning and risk to self and others and the family/caregiver’s potential, skill level and capacity, with appropriate supports, to manage the behaviors that put the child at risk.

4. "Cultural and linguistic competency" means a core competency within the practice of behavioral health services. It includes the understanding that perception of severe emotional disorders, crises and their causes vary by culture. Culture influences help-seeking behaviors and attitudes toward mental health services and emotional well-being. Linguistic competency includes:

a. Phone lines and web sites that assure access for people who are deaf or hearing impaired

b. Interpretation services available within the two (2) hour time period for Emergency Services

c. Translated materials/forms for persons who do not speak or read English in the communities served by the Emergency Services Program

5. "Family support worker" means a person who has first-hand family experience with mental health emergency service interventions as a parent, sibling or consumer and who is available to the family as part of the follow up service plan developed by the Clinician and the family.

6. "Follow up service plan" means the resolution to the mental health crisis that is developed by the Clinician in partnership with the parent or legal guardian of the child. The plan considers the strengths of the family and child, considers all available community services and matches the services to the needs of the child and family.

7. "Mental health emergency" means a situation perceived by a child, adolescent, caretaker, relative, friend, school professional, healthcare professional, police, or other public safety personnel in the care of, or directly involved with, a child or adolescent that poses a risk of harm to the child, family or other person due to a mental illness.

8. "Mental health emergency service interventions" means steps that are taken by a mental health provider to address a mental health crisis including telephone contact, crisis evaluation in the community and follow up service planning and implementation. These interventions take place in a community setting, including a school, police station, residential program, shelter, day care center, community mental health center, community health center, hospital emergency room or other community setting that the family and the Clinician agree is safe and clinically appropriate to resolve the mental health crisis.

9. "Pre-certification" means the process of obtaining approval from the third-party payer, which is required as a condition of payment for a specific benefit prior to the service being provided. This regulation requires the Clinician involved in the crisis evaluation to seek approval from the payer, as required by RIte Care, for the services that the family and Clinician determine appropriate for the mental health needs of the child.

10. "System of Care (SOC)" means core principles and values that are strength- based, child-centered and family-driven. SOC involves establishes and supports a range of easily accessible services for children and adolescents with serious emotional disturbances. The services are culturally and linguistically competent and emphasize natural and community-based supports that complement mental health services provided by professionals in agency and hospital settings.

11. "Utilization review" means prospective, concurrent or retrospective assessment of the medical necessity and appropriateness of the allocation of health care services of a provider, given or proposed to be given to a patient or group of patients, as defined in the Utilization Review of Health Care Services (216-RICR-40-10-20) cited above.

A. In order to be certified for emergency services, the Emergency Service Provider Organization (hereinafter, the Provider) must include a telephone crisis hotline, face-to-face interventions in the community and the means to develop and implement a follow up plan to access community-based and 24-hour services.

B. The Provider meets the standards established under each component.

C. Telephone Contact, Support and Follow up

1. The Provider maintains a telephone system for families that includes:

a. A phone line and a number which answered by a live voice twenty-four hours per day, seven days per week, 365 days per year. The answering service or Provider must have the capacity to ensure accessibility for callers who speak a language other than English.

b. The caller has telephone access to the Clinician within fifteen minutes of the initial call to discuss the crisis and to develop a follow up service plan based on the family’s need and collaboration on next steps.

c. The Provider tracks all phone calls, measures and reports to the Department on the:

(1) Source of the call - parent, guardian, child or collateral party;

(2) Percentage of calls answered within fifteen minutes of the original request;

(3) Number of calls per month.

(4) Percentage of calls that resulted in a face-to-face intervention.

2. The Provider works with the Department, the Department of Human Services (DHS) and RIte Care to publicize the service throughout their service delivery area including in languages other than English in diverse communities.

D. The Provider establishes emergency service intervention policies and procedures that meet the following criteria:

1. Families, caregivers, health care professionals and others who are working with a child experiencing a mental health crisis have access to a Department-certified Mental Health Emergency Service Intervention Team that consists of the Clinician with back-up from a clinical supervisor/ administrator. The Clinician may consult with additional qualified treatment professionals, including a child- trained psychiatrist licensed to practice medicine in Rhode Island.

a. The Clinician provides face-to-face crisis counseling, evaluation of the current mental health emergency and the development of a follow up service plan for a family with a child experiencing a mental health crisis.

b. The face-to-face contact takes place within two hours of the family’s request regardless of the time of day of the call.

c. The clinical supervisor is available to the Clinician and collateral providers for telephone consultation on the assessment and care planning and returns pages or phone calls within fifteen minutes of the request from the Clinician.

2. The family and the Clinician jointly determine the location for the face-to-face crisis intervention to accommodate family needs and preferences, provide for the timeliest and clinically appropriate setting to gather relevant information, increase the chances of de- escalating the crisis and protect the physical safety of all parties.

3. The Clinician meets with the child and family and, as part of the intervention, offers support, completes a crisis evaluation, assesses the child and family for risk to harm self or others and engages the family and collateral providers in the assessment and follow up service planning process.

4. The Provider follows up with families to make sure that the plan was implemented.

E. The Provider establishes policies and procedures to complete the emergency service intervention with follow up service planning including:

1. The Clinician works with the family to resolve the mental health crisis and to promote the health and safety of the child and the family. The Clinician collaborates with the family to identify services in the follow up plan that build on the family’s strengths, needs, and preferences.

2. The Provider ensures all staff are familiar with the full range of community, residential and hospital-based services that can best match the family’s needs, strengths and preferences.

3. The Clinician discusses the value of a Family Support Worker with the family and, if the family identifies the need for such support, makes arrangements for a follow up face-to-face visit or telephone call to the family.

4. The Clinician is also familiar with clinical eligibility criteria and authorization procedures of RIte Care.

5. The Clinician makes an appropriate referral to a program and/or service based on the child-family assessment and mutually identified needs. The Clinician and/or his/her organization also complete any pre-certification required by the third party payer or managed care organization.

6. The Provider ensures that the follow up service planning process includes:

a. The Clinician discusses the follow up that the family prefers and makes arrangements to contact the family and/or the referral source the following day to make sure that the follow up resource was available.

b. The Provider has a form that notes the legal guardian’s signed agreement on the type of follow up in the encounter document or emergency evaluation that is part of the child’s medical record.

c. The Provider is available to the child and family for follow up contact for seventy-two hours after the initial crisis intervention if other community resources are not immediately available.

d. The Provider establishes a complaint and grievance procedure if the family disagrees with the follow up service plan.

F. Standards for Child - Family Competency

1. In order to be certified to provide emergency service interventions, the Provider must establish a policy for the recruitment and/or training of emergency service staff. Staff must possess the following clinical skills:

a. Child interview skills, including assessment of child’s coping skills, determining the locus of control and evaluating the risk of the child to harm him/herself or others based on intent, means and opportunity based on the developmental level and cognitive ability.

b. Crisis de-escalation and diffusion of the behavioral health emergency, engaging both the child and the family in the intervention, gathering important information to make the best decision on follow-up care, partnering with the families on the follow-up plan and confirming with the families that the plan has been implemented.

c. Family interview skills, including assessment of the family’s coping skills and their ability to manage crisis.

d. The ability to assess family supports and global risks based on the environment of supports and obstacles in which the family lives.

e. The ability to incorporate family strengths and skills into the risk assessment and follow up plan.

f. Skill in partnering with parents using family-centered language in planning follow-up services that match the needs of the child and family.

g. Diagnostic formulation according to DSM IV-R criteria and child-specific risk criteria.

h. Age appropriate crisis interventions designed to reduce immediate symptoms of behavioral health risk.

i. Application of diagnostic formulation to determine the child’s behavior as a Serious Emotional Disturbance, the immediate risk factors of the child’s potential to harm him/herself or others and the child’s and family’s strengths as factors in managing the crisis.

j. Skill in applying differential interventions for families from diverse cultural, linguistic and ethnic backgrounds, ability to work effectively with interpreters and clinical skills to provide interventions within a cultural context.

2. In order to be certified, the Provider must confirm in writing that staff who provide child emergency service interventions possess knowledge of:

a. Age appropriate behavior, attitude and conceptualization;

b. Appropriate roles of parents with children based on age and behavior and culture;

c. Indications and side effects of psychiatric medications that are commonly prescribed for children and adolescents and how such medications are metabolized based on race, ethnicity and age;

d. The full range of legal status categories of children involved with the Department and the rights of children and families to consent to or refuse treatment;

e. How children and families of diverse cultures view sharing information, behavioral health and social services and emergency/crisis situations;

f. Informal supports and extended family support as valid interventions; and

g. Matching services to the assessed needs of the child and family based on SOC principles for an array of community- based services in a range of cultural contexts.

3. In order to be certified as a Provider, the organization must provide ongoing training, consultation, support and updated information to staff who provide emergency service interventions. The Provider ensures a minimum of ten hours of training per year on best and promising practices in children’s behavioral health and monthly updates on the changing network of managed care programs and community resources including:

a. The types of RIte Care and third party payers, the behavioral health benefit packages and the behavioral health provider network of each insurance company.

b. The eligibility and/or admission criteria for the children’s behavioral health treatment programs.

c. A list of contact names and phone numbers for the community providers of children’s behavioral health treatment, advocacy, support and collateral services.

4. The Provider has an identified subject matter expert on the SOC referral process and how to obtain access to social service, housing, employment and other Medicaid-funded services.

5. The Provider ensures all staff have knowledge of culture-specific services, the linguistic capacity of community services and the ability to work effectively with an interpreter of sign language and/or spoken language.

6. The Provider identifies a clinical subject matter expert who can provide training and consultation to the emergency services staff based on his/her expertise on the current best practice interventions in the field of children’s behavioral health.

G. Program Monitoring and Quality Improvement

1. The Provider collects encounter data on emergency service interventions monthly as described herein.

a. Complete and forward mandated forms and reports to the Department.

b. Provides aggregate report to the Department monthly.

2. The standardized report includes aggregate data of emergency service interventions that capture the age, gender, ethnicity, status with the Department, child’s living arrangement, insurance coverage, time of day, day of week, location of intervention and type of disposition.

3. The Provider develops an internal process to review complaints from the family or other parties involved in the intervention.

4. The Provider has a process, consistent with the DHS Fair Hearing process, of resolving disagreements with the family around the follow up service plan.

H. The Provider is credentialed by and contracts with all RIte Care HMO’s and is knowledgeable of the authorization procedures required to access services identified in the follow up service plan.

I. The Provider has an established training protocol in children’s behavioral health that includes an annual plan to address the best practices and current findings related to working with children with serious emotional disturbances and their families in a culturally and linguistically competent manner and from an individual and family systems perspective.

A. Organizations applying to be certified as Providers of children’s emergency service interventions complete and submit an application for certification for mental health emergency interventions to the Department. The following information must be included with the application:

1. Documentation of contracts with the RIte Care HMOs as a behavioral health provider.

2. Documentation of Certification by the Council on Accreditation of the Child Welfare League of America (COA) or Joint Commission on Accreditation of Hospital Organizations (JCAHO) or Commission on Accreditation of Rehabilitation Facilities (CARF) and licensure by the Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH).

3. A description of the organization’s delivery of children’s emergency service interventions that specifically addresses:

a. Staffing of Child-Family competent clinicians;

b. Twenty-four hour per day, seven (7) day per week live telephone coverage with administrative back up;

c. Determination of child-family competency in recruitment, training and supervision of clinical staff;

4. A commitment to reporting to the Department and RIte Care on monthly activity using the Department reporting format and a commitment to develop internal review mechanisms to monitor compliance with these standards.

5. A statement identifying the geographical areas the organization can reliably serve based on knowledge of and access to local mental health and community-based services and the organization’s ability to meet the timelines within these standards.

6. Elements of the organization’s quality improvement plan that relate to children’s behavioral health services.

7. A statement assuring compliance with Department Operating Procedure 100.0215, Criminal Record Checks and 100.0155, Clearance of Agency Activity.

B. Applicant Eligibility

1. Any organization that provides behavioral health services to children and meets the criteria below may apply to become a certified Provider.

a. Organization is licensed as a community mental health center by BHDDH.

b. Organization is a certified Medicaid provider in Rhode Island and has one of the following:

(1) Current accreditation from JCAHO

(2) Current certificate from CARF

(3) Current certification from COA

c. Organization is a certified Medicaid provider, currently contracts (and is in good standing) with a RIte Care HMO.

C. Approval Process

1. Department staff review and make a recommendation regarding certification to the designated Administrator. The recommendation may be for full certification or provisional certification. If provisional certification is recommended, conditions for full certification are identified.

2. An organization whose application is not approved for certification may appeal as described in Department Operating Procedure 100.0040, Complaints and Hearings.

The Department certifies a Provider for two (2) years from the approval date based on satisfactory compliance with this regulation.