24 Miss. Code. R. 2-54.19 - Program Requirement Four (4): Scope of Services - Screening, Assessment, and Diagnosis
A. The CCBHC
directly, or through a DCO, provides screening, assessment, and diagnosis,
including risk assessment for behavioral health conditions. In the event
specialized services outside the expertise of the CCBHC are required for
purposes of screening, assessment, or diagnosis (e.g., neuropsychological
testing or developmental testing and assessment), the CCBHC refers the person
to an appropriate provider. When necessary and appropriate screening,
assessment and diagnosis can be provided through telehealth/telemedicine
services. Note: Refer to the program requirement regarding coordination
of services and treatment planning.
B. Screening, assessment, and diagnosis are
conducted in a time frame responsive to the needs and preferences of the person
receiving services and are of sufficient scope to assess the need for all
services required to be provided by the CCBHC.
C. The initial evaluation (including
information gathered as part of the preliminary triage and risk assessment,
with information releases obtained as needed), as required in Program
Requirement Two (2), includes at a minimum:
1.
Preliminary diagnoses.
2. The
source of referral.
3. The reason
for seeking care, as stated by the person receiving services or other people
who are significantly involved.
4.
Identification of the immediate clinical care needs related to the diagnosis
for mental and substance use disorders of the person receiving
services.
5. A list of all current
prescriptions and over-the counter medications, herbal remedies, and dietary
supplements and the indication for any medications.
6. A summary of previous mental health and
substance use disorder treatments with a focus on which treatments helped and
were not helpful.
7. The use of any
alcohol and/or other drugs the person receiving services may be taking and
indication for any current medications.
8. An assessment of whether the person
receiving services is a risk to self or to others, including suicide risk
factors.
9. An assessment of
whether the person receiving services has other concerns for their safety, such
as intimate partner violence.
10.
Assessment of need for medical care (with referral and follow-up as
required).
11. A determination of
whether the person presently is, or ever has been, a member of the U.S. Armed
Services.
12. For children and
youth, whether they have system involvement (such as child welfare and juvenile
justice).
D. A
comprehensive evaluation is required for all people receiving CCBHC services.
Subject to applicable state, federal, or other accreditation standards,
clinicians should use their clinical judgment with respect to the depth of
questioning within the assessment so that the assessment actively engages the
person receiving services around their presenting concern(s). The evaluation
should gather the amount of information that is commensurate with the
complexity of their specific needs and prioritize preferences of people
receiving services with respect to the depth of evaluation and their treatment
goals. The evaluation shall include:
1.
Reasons for seeking services at the CCBHC, including information regarding
onset of symptoms, severity of symptoms, and circumstances leading to the
presentation to the CCBHC of the person receiving services.
2. An overview of relevant social supports;
social determinants of health; and health related social needs such as housing,
vocational, and educational status; family/caregiver and social support; legal
issues; and insurance status.
3. A
description of cultural and environmental factors that may affect the treatment
plan of the person receiving services, including the need for linguistic
services or supports for people with LEP.
4. Pregnancy and/or parenting
status.
5. Behavioral health
history, including trauma history and previous therapeutic interventions and
hospitalizations with a focus on what was helpful and what was not helpful in
past treatments.
6. Relevant
medical history and major health conditions that impact current psychological
status.
7. A medication list
including prescriptions, over-the counter medications, herbal remedies, dietary
supplements, and other treatments or medications of the person receiving
services. Those identified in a Prescription Drug Monitoring Program (PDMP)
that could affect their clinical presentation and/or pharmacotherapy, as well
as information on allergies including medication allergies, should be
included.
8. An examination that
includes current mental status, mental health (including depression screening,
and other tools that may be used in ongoing measurement-based care) and
substance use disorders (including tobacco, alcohol, and other
drugs).
9. Basic cognitive
screening for cognitive impairment.
10. Assessment of imminent risk, including
suicide risk, withdrawal and overdose risk, danger to self or others, urgent or
critical medical conditions, and other immediate risks including threats from
another person.
11. The strengths,
goals, preferences, needs, and other factors to be considered in treatment and
recovery planning of the person receiving services.
12. Assessment of the need for other services
required by the statute (i.e., peer and family/caregiver support services,
targeted case management, psychiatric rehabilitation services).
13. Assessment of any relevant social service
needs of the person receiving services, with necessary referrals made to social
services. For children and youth receiving services, assessment of systems
involvement such as child welfare and juvenile justice and referral to child
welfare agencies as appropriate.
14. An assessment of need for a physical exam
or further evaluation by appropriate health care professionals, including the
primary care provider (with appropriate referral and follow-up) of the person
receiving services.
15. The
preferences of the person receiving services regarding the use of technologies
such as telehealth/telemedicine, video conferencing, remote patient monitoring,
and asynchronous interventions.
E. Screening and assessment conducted by the
CCBHC related to behavioral health include those for which the CCBHC will be
accountable pursuant to Program Requirement Five (5) and Rule 54.33 of these
criteria. The CCBHC should not take non-inclusion of a specific metric in Rule
54.33 as a reason not to provide clinically indicated behavioral health
screening or assessment.
F. The
CCBHC uses standardized and validated and developmentally appropriate screening
and assessment tools appropriate for the person and, where warranted, brief
motivational interviewing techniques to facilitate engagement.
G. The CCBHC uses culturally and
linguistically appropriate screening tools and approaches that accommodate all
literacy levels and disabilities (e.g., hearing disability, cognitive
limitations), when appropriate.
H.
If screening identifies unsafe substance use including problematic alcohol or
other substance use, the CCBHC conducts a brief intervention and the person
receiving services is provided a full assessment and treatment, if appropriate
within the level of care of the CCBHC or referred to a more appropriate level
of care. If the screening identifies more immediate threats to the safety of
the person receiving services, the CCBHC will take appropriate action as
described in Program Requirement Two (2).
Notes
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No prior version found.