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Enhanced Therapeutic Foster Care Alternative or “in Lieu of” Service Definition SERVICE NAME: Enhanced Therapeutic Foster Care PROCEDURE CODE: S5145 U5 DESCRIPTION Enhanced Therapeutic Foster Care (“ETFC”) is a family-based, person-centered residential treatment intervention intended for individuals who have complex mental health and/or substance use disorder or dually diagnosed mental health/intellectual developmental disability needs. To be successfully implemented, ETFC requires intensive, active, and evidenced-based therapeutic interventions with the individual and their family by a trained direct support professional. This service also requires a higher intensity and frequency of consultation with qualified professionals, licensed psychiatrists, licensed psychologists, and other licensed medical professionals than Residential Treatment Level II- Family Type. The provider delivers and implements interventions consistent with a Shared Parenting framework to facilitate reintegration of the member to their family home as effectively as possible. The service will not only strive to maintain a therapeutic relationship with the individuals and families served, it will also be responsive to the changing needs of the individual and family throughout treatment. To this end, staff will be appropriately trained and supported in crisis deescalation and non-restrictive interventions. The ETFC family is not necessarily awake during sleep time but must be constantly available to respond to a member’s needs. Members are involved in educational, vocational, social or other activities, except for periods of planned respite. The provider educates and promote positive responses to maladaptive behaviors including but not limited to verbal and physical aggression. The provider will aid the member in reestablishing healthy daily functioning, self-management skills and age-appropriate social skills, including reestablishing communication skills and unlearning maladaptive behaviors. The provider assists the member with restoring healthy cognitive behavioral approaches to managing stressors which will assist the member in stepping down to a lower level of care. During this process, the provider addresses modes of shared parenting with the guardian. This service is restricted to one member in the home who may require higher levels of supervision and behavioral management than is offered in a group setting. This service provides an intensive development of age-appropriate behaviors in which therapeutic interactions are dominant. This focus includes assisting the member in improving relationships at school, work or other community settings. There is an emphasis on individualized interventions for age-specific skill acquisition to meet the clinical needs of each member enabling him or her to achieve or maintain their highest level of independent functioning.
PROGRAM REQUIREMENTS Specific interventions aligned with the description of the program are outlined below: 1) The ETFC family, who provides temporary substitute care to the individual being separated from their biological or adoptive family, has a minimum of one face-to-face visit with the member and guardian prior to the member’s ETFC placement; 2) If the member is transitioning from a higher level of care, the Enhanced Therapeutic Foster Care family participates in the Discharge Planning Child and Family Team Meeting from the higher level of care; 3) For members in the custody of a county Department of Social Services (DSS), a shared parenting meeting, as described in the NC Division of Social Services, Family Services Manual, Section 1201- Child Placement Services, Shared Parenting, must occur between the member’s guardian/biological/adoptive family and the DSS foster family/caregiver within seven (7) days of placement with DSS. Shared Parenting is also to be utilized with members not in the custody of DSS and the Shared Parenting meeting for these members shall occur within 14 days of placement with DSS. Any reasons for not utilizing Shared Parenting and/or not holding the initial meeting within the above time frames must be clearly documented in the member record; Vaya Health | Enhanced TFC ILOS Definition Copyright © 2021 Vaya Health. All rights reserved.
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4) Weekly meetings occur between the ETFC Qualified Professional (QP) overseeing the member’s case and the ETFC family to assess member progress, provide professional support and assist in altering interventions as needed to achieve maximum therapeutic effect. One meeting per month may be conducted by telephone; 5) Any planned or scheduled monthly respite for the ETFC parents must be included in the member’s treatment plan; 6) Documented weekly telephone or face-to-face contact with the member’s family/legally responsible person occurs to provide updates on treatment progress and gain insight into member behaviors; discussion of parenting skills also occurs during this meeting to facilitate the member’s eventual transition back to their natural home setting 7) Involvement of family/guardian/caregiver in Child and Family Team Meetings. The following service delivery requirements apply: 8) This service in the family setting shall include individualized and intensive training in a family home designed to minimize the occurrence of behaviors related to functional deficits to ensure safety during the presentation of highly inappropriate behaviors or to maintain an optimum level of functioning. 9) Specific and individualized psychoeducational and therapeutic interventions shall include: i) development or maintenance of age appropriate daily living skills; ii) anger management; iii) development of age-appropriate social skills appropriate for peer group; iv) family living skills; v) communication skills; vi) stress management; vii) relationship support; viii) comparable activity; and/or ix) intensive crisis or near crisis management including de-escalation interventions. 10) Direct and active intervention shall include, at a minimum i) assisting members in the process of being involved in and maintaining their health and safety in naturally occurring community support systems; and ii) supporting the member in developing personal resources (assets, protective factors, etc.). 11) Provider must maintain and make available to the MCO, upon request, discharge level of care data with a goal of at least 50% of youth served being diverted from out of home placement after receiving the service. 12) Provider must maintain and make available to the MCO, upon request, diversion data on how many members in ETFC are diverted from emergency room or inpatient services due to interventions rendered in ETFC settings.
EXPECTED OUTCOMES Treatment setting stability: Members referred to this level of care are more likely to have experienced multiple placement settings. It is expected that crisis plans will be developed and refined according to members’ needs to address crisis situations as they arise and maintain placement stability. Lessons learned from crisis are expected to inform future interventions in this setting, not as a precursor to certain discharge to more intensive levels of care. Additionally, caregivers in this setting are expected to have appropriate training in crisis de-escalation techniques and in alternatives to restrictive intervention. Access to appropriate levels of respite for caregivers is expected as is a consistent level of professional support for direct care staff in this setting. It is expected that, when possible, the member will return to their natural family setting. If alternate placement is needed, then the least restrictive most appropriate level will be chosen. Child and Family Teams (CFT) should plan around crisis, transition or residential placement. Barriers to returning to original setting shall be documented and an action plan shall be created to address the barriers.
ELIGIBILITY CRITERIA Members ages three and older are eligible for ETFC when the following criteria are met: • Member has a diagnosis of a mental health or substance use disorder (as defined by the DSM-5, or any subsequent editions of this reference material), other than a sole diagnosis of intellectual and developmental disability; AND • Member is at risk of placement in institutional level of care or is ready to be discharged from this level of care; AND • Does not require 24-hour continuous “eyes-on” supervision; AND • There is an immediate need for structured treatment and reduction of environmental stress and without, youth would likely be in a higher level of care or present to an inpatient facility for care; AND Vaya Health | Enhanced TFC ILOS Definition Copyright © 2021 Vaya Health. All rights reserved.
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Member is experiencing any one of the following (may be related to the presence of moderate affective, cognitive or behavioral problems or developmental delays/disabilities): 1. Moderate to severe difficulty maintaining placement in the naturally available family or lower level treatment setting; 2. Frequent and severely disruptive verbal aggression and/or frequent and moderate property damage and/or occasional, moderate aggression toward self and/or others; and 3. Moderate to severe functional problems in school or vocational setting or other community setting;
AND Member has deficits in ability to manage personal health, welfare, and safety without intense support and supervision. AND For members identified with or at risk for inappropriate sexual behavior: 1. At least one incident of inappropriate sexual behavior accompanied by risk for ongoing inappropriate sexual behaviors; OR 2. Deficits that put the community at risk unless specifically treated for sexual aggression problems.
CONTINUED SERVICE CRITERIA The member is eligible to continue this service if: • The member continues to meet the Eligibility Criteria AND the desired outcome or level of functioning has not been restored, improved or sustained over the time frame outlined in the member’s service plan or the member continues to be at risk for relapse based on history or the tenuous nature of the functional gains OR any one or the following apply: a. Member has achieved initial service plan goals and additional goals are indicated. b. Member is making satisfactory progress toward meeting goals. c. Member is making some progress, but the service plan (specific interventions) needs to be modified so that greater gains, which are consistent with the member’s pre-morbid level of functioning, are possible or can be achieved. d. Member is not making progress; the service plan must be modified to identify more effective interventions. e. Member is regressing; the service plan must be modified to identify more effective interventions.
DISCHARGE CRITERIA The member meets the criteria for discharge if any one of the following applies: a. The level of functioning has improved with respect to the goals outlined in the service plan and can reasonably be expected to maintain these gains at a lower level of treatment. b. The member no longer benefits from service as evidenced by absence of progress toward service plan goals and more appropriate service(s) is available. *Note: Any denial, reduction, suspension or termination of services requires notification to the member or legal guardian about their appeal rights.
SERVICE MAINTENANCE CRITERIA If the member is functioning effectively at this level of treatment and discharge would otherwise be indicated, this level of service shall be maintained when it can be reasonably anticipated that regression is likely to occur if the service were to be withdrawn. This decision should be based on at least one of the following: a. There is a history of regression in the absence of residential treatment or at a lower level of residential treatment. b. There are current indications that the member requires this residential service to maintain level of functioning as evidenced by difficulties experienced on therapeutic visits or stays in a non-treatment residential setting or in a lower level of residential treatment. c. In the event there are epidemiologically sound expectations that symptoms will persist and that ongoing treatment interventions are needed to sustain functional gains, the presence of a DSM-5, or any subsequent editions of this reference material, diagnosis would necessitate a disability management approach. *Note: Any denial, reduction, Vaya Health | Enhanced TFC ILOS Definition Copyright © 2021 Vaya Health. All rights reserved.
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suspension or termination of services requires notification to the member or legal guardian about their appeal rights.
PROVIDER REQUIREMENTS Enhanced Therapeutic Foster Care is a 24-hour service. This service is licensed under the Division of Social Services 131D family setting homes.
STAFFING REQUIREMENTS This treatment may be provided in a natural family setting with one or two surrogate family members providing service to one member per home. Specific training requirements prior to service delivery: 1. In addition to the minimum requirements in North Carolina General Statute 131D-10, Article 1A, as well as 10A North Carolina Administrative Code 70E and 27G Enhanced Therapeutic Foster Care parents and supervising agency staff must be trained in the following: 2. Shared Parenting training. 3. Specific training in working with clients dually diagnosed with Mental Health/Intellectual Developmental Disability disorders including autism 4. Trauma Informed Care. 5. Specific training in working with members who display sexually inappropriate behaviors 6. It is expected that the service will be consistent with the LME/MCO clinical guidelines and best practices. It is expected that the Enhanced Therapeutic Foster Care provider will have utilized evidence-based interventions to achieve these aims.
SERVICE ORDERS Service orders are a mechanism to demonstrate medical necessity for a service and are based upon an assessment of each member’s needs. They are required for each individual service and may be written by a Medical Doctor (MD), Doctor of Osteopathic Medicine (DO), Licensed Psychologist, Nurse Practitioner (NP), or Physician Assistant (PA). a. Backdating of service orders is not allowed. b. Each service order must be signed and dated by the authorizing professional and must indicate the date on which the service was ordered. c. A service order must be in place prior to or on the day that the service is initially provided to bill Medicaid for the service. Even if the member is retroactively eligible for Medicaid the provider shall not be able to bill Medicaid without a valid service order. Service orders are valid for one year from the date of plan entered on a Person-Centered Plan (PCP). Medical necessity must be reviewed, and services must be ordered at least annually, based on the Date of Plan. (Refer to the Division of Mental Health, Developmental Disabilities and Substance Abuse Services (DMHDDSAS) Person Centered Planning Instruction Manual and the DMHDDSAS Records Management and Documentation Manual for additional information on service orders, signatures, and the date of plan.)
UTILIZATION MANAGEMENT Prior authorization is required for this service. Initial authorizations for service shall not exceed 60 days, and concurrent authorizations for service shall not exceed 90 days. Utilization review shall occur within 30 days of the end date of the prior authorization for concurrent requests. 1 Unit = 1 Day Length of stay for Enhanced Therapeutic Foster Care is expected to be no more than 12 months. Coordination of wrap around, home or community-based treatment services must be established for the family upon discharge. Vaya Health | Enhanced TFC ILOS Definition Copyright © 2021 Vaya Health. All rights reserved.
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The process for a member to enter this service includes completion of a face-to-face comprehensive clinical assessment. This assessment shall be completed prior to admission to the ETFC home, and includes the identification of eligibility criteria for this service. A Service Authorization Request, Person Centered Plan, Service Order, Comprehensive Crisis Prevention and Intervention Plan, and a CALOCUS (or other level of care tool such as the ASAM or CANS) must be submitted for review for entry into the service.
DOCUMENTATION REQUIREMENTS The minimum standard is a daily service note that includes the following: a. Member’s name; b. Member’s Medicaid identification number; date of service; c. Purpose of contact; d. Description of the provider’s interventions; e. Effectiveness of the intervention; and f. Signature of the staff providing the service. Treatment logs or preprinted check sheets are not sufficient to provide the necessary documentation.
SERVICE EXCLUSIONS Periodic Services shall not be used to augment ETFC.
EPSDT SPECIAL PROVISION: EXCEPTION TO POLICY LIMITATIONS FOR A MEDICAID MEMBER UNDER 21 YEARS OF AGE 42 U.S.C. § 1396d(r) [1905(r) of the Social Security Act] Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) is a federal Medicaid requirement that requires the state Medicaid agency to cover services, products, or procedures for Medicaid member under 21 years of age if the service is medically necessary health care to correct or ameliorate a defect, physical or mental illness, or a condition [health problem] identified through a screening examination** (includes any evaluation by a physician or other licensed clinician). This means EPSDT covers most of the medical or remedial care a child needs to improve or maintain their health in the best condition possible, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems. Medically necessary services shall be provided in the most economic mode, if the treatment made available is similarly efficacious to the service requested by the member’s physician, therapist, or other licensed practitioner; the determination process does not delay the delivery of the needed service; and the determination does not limit the member’s right to a free choice of providers. EPSDT does not require the state Medicaid agency to provide any service, product or procedure: 1. that is unsafe, ineffective, or experimental or investigational. 2. that is not medical in nature or not generally recognized as an accepted method of medical practice or treatment. Service limitations on scope, amount, duration, frequency, location of service, and other specific criteria described in clinical coverage policies may be exceeded or may not apply as long as the provider’s documentation shows that the requested service is medically necessary “to correct or ameliorate a defect, physical or mental illness, or a condition” [health problem]; that is, provider documentation shows how the service, product, or procedure meets all EPSDT criteria, including to correct or improve or maintain the member’s health in the best condition possible, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems. If the service, product, or procedure requires prior approval, the fact that the member is under 21 years of age does NOT eliminate the requirement for prior approval.
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Clinical Strategies | Rev. 03.07.2019 Version 1.0