Utilization Management means that some entity uses clinical and other criteria to determine what services a person is eligible to receive, at what level of intensity, and for how long. The state plan proposes that an independent contractor be hired to provide this service statewide. The plan specifically states that there shall be NO financial incentive for denying care. The contractor will also provide each LME and the State a wide range of statistical and episode data. Presumably this contractor would be the same one providing the 800-line phone access line.

The contractor will use eligibility criteria established by the state. These criteria have not yet been developed. All local programs and service providers would need to have services approved through this statewide utilization management entity. How would this work? An LME or service provider would call the UM contractor and request a particular service(s) for a particular client based on a clinical assessment of that individual. The contactor would compare the information given to the established state criteria to determine if the individual met the criteria to receive the service, how often, and for how long.

After an individual has gone through the uniform portal and is determined to meet the criteria of a target population, what services can they receive? Below are excerpts from the plan that detail who gets what:

• Inpatient services
• Outpatient services
  Medication evaluation and management
  Individual therapy
  Group therapy
  Case management (including transition case management from hospital to community, which may require more than 30 days prior to discharge)
  Education around mental illness, physical health, and substance abuse issues
  Peer support
  Family intervention
  Relapse/decompensation prevention services
  
• Rehabilitative services

CBS (to include both community integration and cognitive or other skill teaching as needed)
Partial hospitalization

• Crisis services, including but not limited to

Crisis phone
Crisis face to face services
Transitional crisis services (host home)
Facility based crisis services
Mobile crisis services

All of the services above, plus:

• Outpatient services:
• Assertive outreach
• Assertive Community Treatment (ACTT)
• Personal Assistance
• Rehabilitative Services
• Psychosocial rehabilitation, clubhouse
• Supported employment
• Day Activity
• Residential
• Supervised Living
• Supported Housing
• Respite

1. SPMI and Multiple Diagnoses: Rather than additional services, this priority population requires that the existing services be integrated services, such that all diagnoses are addressed in an integrated manner. In addition, the service continuum should have the capacity to provide care to persons with multiple diagnoses (e.g. detoxification services should have the capacity to work with consumers with schizophrenia and alcoholism, crisis services should have the capacity to work with consumers with bipolar disorder and mental retardation), and should have staff that are appropriately cross-trained. These services should follow best practice models such as those outlined in the Division’s clinical guidelines.
2. Homeless Mentally Ill: Cross-disability assertive outreach should be available, and local authorities should proactively seek out and address the needs of homeless consumers.
3. Mentally Ill Adults in Criminal Justice System: Case management services should include transitional case management prior to an individual’s release from jail or prison, and should include linkage with probation. Jail diversion programs (which can consist of assertive outreach, case management, and local agreements between court, jail, and mental health system) should be available.
4. Elderly Persons: Outpatient services should promote acceptance and integration of geriatric clients into other community services such as adult day care, adult day health and other activities which assist clients in maintaining independent living skills. Specialized day treatment programs should promote rehabilitation and involvement in age appropriate activities and interaction with peers. Consultation with facilities such as nursing homes, adult care homes and other caregivers including clients’ families regarding management of behaviors related to serious mental illness, including dementia, should be provided. Inpatient psychiatric services should have staff knowledgeable in stabilization and treatment of acute episodes of mental illness and behaviors that are dangerous to self or others in the geriatric population.
5. Deaf Mentally Ill Persons: Services should have the capacity to provide care to deaf individuals in a culturally competent manner, including access to translators and service providers fluent in ASL and knowledgeable about deaf culture.

Child and Adolescent Target Populations

Services will be provided using a system of care (SOC) approach. This approach involves:

1. A Statewide Array of Broad and Flexible Services and Supports: Children with complex behavioral health needs and their families will have ready access to a local, regional and state level array of residential and non-residential service and support options that cut across agency boundaries. The foundations of the array are Family Support, Crisis Response and Crisis Stabilization services.
   
2. Comprehensive, Outcome-Based Plans of Care
   • Common Screening and Assessment Processes
   • Wraparound Approach: A key component of the System of Care is adherence to a "wraparound" approach. The term wraparound refers to particular service/support modalities, i.e., flexible, discrete goods, services and/or support resources that cannot typically be accessed through formal/categorical agencies.
   • Child and Family Teams: Services and supports will be planned, delivered and monitored for each child and family through their Child and Family Team. The composition of the team will be unique for each family, comprised of those persons who are important in their everyday lives, according to the youth and family
     
3. Collaborative Management, Support and Accountability: The comprehensive and effective care that these children and families need requires a multi-agency and community effort. It requires that local and state program directors, administrators, and other decision-makers work together with families and communities in a reciprocal way – finding and building common goals, finding concrete ways to promote collaboration, implement best practices and decrease fragmentation instead of protecting turf and business as usual.
   
4. Integrated Funding, Financial Incentives and Cost-Sharing: Child-serving agencies will realign funding policies to reduce duplication of effort. Resources will be shared and funds braided to maximize existing services and eliminate cost shifting. Braiding funds means that each agency’s/organization’s funds retain their respective identity and requirements, but that these monies are used or ‘braided’ together to fund one Integrated Service Plan.
   
5. Best Practices & Knowledge Dissemination

CATEGORY B: SERVICES FOR CHILDREN WITH MILD MENTAL HEALTH PROBLEMS AND THEIR FAMILIES

Category B services are the primary services delivered to children with mental health needs and families. The majority of children with emotional and behavioral needs will receive assistance via Category B services. Based on current utilization figures, most children and families receiving assistance through the child and family mental health system should be able to have their needs met through Category B service components, i.e., if a full array of services and supports are available in Category A and B, most children will not become at risk for out of home placements and require Category C or D services.

Category B services will be available within each catchment area to all children/youth who:

1. Meet the criteria for Priority Populations 1, 2, or 3 (Severe, Moderate or Mild)
2. Meet Clinical Necessity criteria

CATEGORY B SERVICES

1. Early Childhood Services
2. Community Based Services
3. Evaluation (Psychiatric/Psychological/Other)
4. Psychotherapy: Individual, Group, Family
5. Medication Management
6. Therapeutic Respite
7. Treatment Support Services
8. Wraparound

CATEGORY C: SERVICES FOR CHILDREN WITH MODERATE MENTAL HEALTH PROBLEMS AND THEIR FAMILIES

Category C services are targeted to meet the special needs of children and families who have mental health concerns that cannot be addressed through primary services described in Category B. The goal for services at this level is to develop a systematic response to the critical needs underlying the challenging behaviors and conditions exhibited by children with more severe and persistent mental health issues.

Category C Non-Residential services will be available within each catchment area to those children who:

1. Meet the criteria for Priority Populations 1 or 2 (Severe or Moderate)
2. Meet Clinical Necessity criteria

Category C Residential services will be available locally or within each to those children who:

1. Meet the criteria for Priority Populations 1 or 2 (Severe or Moderate)
2. Meet Clinical Necessity criteria

CATEGORY C SERVICES

1. Intensive Case Management
2. Day Treatment
3. Family Based Residential Care (Level II, Family & Specialized))
4. In Home Therapy/Family Preservation
5. Therapeutic Mentoring
6. Summer/Before/After School Programs
7. Independent Living Skills Training
8. Vocational Placement/Training/Support
9. Group Based Residential (Levels II and III)
10. Supervised Independent Living
11. Wilderness Camp Treatment

CATEGORY D: SERVICES FOR CHILDREN WITH SEVERE MENTAL HEALTH PROBLEMS AND THEIR FAMILIES

Category D services are created to address the full range of needs of families with children who have severe and enduring emotional and behavioral disorders that are unlikely to respond to the resources available through Category A, B, and/or C services. The central organizing principle of Category D services is a belief that as the needs of children and families become more serious and multi-dimensional, the support we offer them should become more unique in order to achieve lasting positive outcomes. Category D services insure that North Carolina can provide an effective response to the most serious mental health needs of children and their families. Through Category D services we determine what to do when existing service and support options have not worked and/or do not appear sufficient to address the range of critical needs of the child and family.

Category D Non-Residential services will be available within each catchment area to those children who:

1. Meet the criteria for Priority Population 1 (Severe)
2. Meet Clinical Necessity criteria

Category D Residential services will be available within each region or at a state level to those children who:

1. Meet the criteria for Priority Population 1 (Severe)
2. Meet Clinical Necessity criteria

CATEGORY D SERVICES

1. ACT Teams
2. Level IV - Group Setting
3. Psychiatric Residential Treatment Facility (PRTF)
4. State Run Residential Treatment Centers
5. Inpatient Hospitals