Continued Stay Review Form

Continued Stay Review Form This is the Maine Behavioral Health ASO CareConnection® Continued Stay Review Form. This form is to be used by providers to submit requests for Continued Stay Reviews for MaineCare members and other consumers as appropriate.

Fields with an (*) next to them are required. Please submit this information via KEPRO CareConnection® Please call KEPRO Provider Relations with any questions, at (866) 521-0027, Option 1.

*Member Information *Member MaineCare ID:

*Member First Name: *Member Last Name:

*Member SSN: *Date of Birth:

*Gender: Female Male Unknown Phone Number (with area code):

*Address of Record:

*City: *State: *Zip Code:

*AMHI Consent Decree Class Member: YES NO

*Race: White Black or African American Alaskan Native Native Hawaiian American Indian Hispanic Asian Other Pacific Islander Other Race Unknown Guardian/Power of Attorney

Guardian Organization (if applicable): Child Welfare Elder Services Office of Cognitive Disabilities

Guardian First & Last Name: Phone Number: Guardian Address:

City: State: Zip Code: Relationship to Member: Family Member Friend Agency Spouse Other

Additional Information:

1 KEPRO OP MH Continued Stay Review v8-1-16

*Administrative Data *Authorization Type: Continued Stay Review *Organization:

* Submission Date: *Requested Start Date of Service:

* Review Type: Adult Mental Health Nursing Home Services Psychological Services Psychological Services Substance Abuse Services Children’s Services

*Category of Service: CHOOSE ALL THAT APPLY Adult Mental Health Children’s Services Community Integration Targeted Case Management Intensive Case Management Inpatient Services Assertive Community Treatment Day Treatment Daily Living Support Services Crisis Support Services Skills Development Infant Mental Health Day Supports Children’s Outpatient Specialized Group Services Family PsychoEducational Crisis Supports Services Child Assertive Community Treatment Hospital Services – Acute Medication Services Home Based Child & Family Behavioral Health Treatment Group Psychotherapy Community Based Treatment without Permanency Medication Management Private Non-Medical Crisis Unit Psychotherapy Treatment Foster Care PNMI Children’s PNMI Services Psychological Services Multidimensional Treatment Foster Care Family PsychoEducational Baxter Fund Services Community Rehabilitation Services Provided by an Educational System Long-Term Supported Employment Rehab and Community Support Services – Section 28 Baxter Fund Services Partial Hospitalization Dorothea Dix/Riverview Intensive Outpatient Program Partial Hospitalization Behavioral Health Homes Intensive Outpatient Program ITRT Referral Home and Community Benefits for Adults Behavioral Health Homes Substance Abuse Services Clubhouse Inpatient Substance Abuse Outpatient Substance Abuse Nursing Home Services Intensive Outpatient Program Nursing Home Services Grant-Funded Adult Services Psychological Services Community Integration Psychological Services Assertive Community Treatment Daily Living Support Services Community Rehabilitation Services

Location (for PNMI, Crisis Units, & Hospitals):

Referral date: Location at Time of Referral: Hospital Community

*Requesting Agency/Facility * Requesting Facility/Agency Name:

* Requesting Staff First & Last Name:

*Requesting Staff Phone (with Area Code):

UM/Supervisor Name/Phone:

*Multiaxial Assessment Date of Diagnostic Assessment:

*Primary Diagnosis: *Co-Occurring Primary Diagnosis:

Axis I Diagnosis I: Axis I Diagnosis II:

Axis II Diagnosis I: Axis I Diagnosis II:

Axis III Diagnosis:

*Procedure Request

*Service Code:

*Frequency: Click here to choose frequency

*Start Date: *NPI Number:

*Units:

*Service length and End date automatically populates based on the Service.

Symptoms/Behavior Summary (Required for Section 17 Services Only)

Agency Involvement Family/Social Involvement Check all that apply: Check all that apply: DHHS Adult Mental Health Family DHHS Child Welfare Spouse/Partner DHHS Elder Services Friends Corrections (Court, JCCO, etc.) Religious Group EAP Community Resources Special ED/504 AA/NA or Self-Help Group None Other: Other:

Rate Overall Level of Family Involvement in Treatment Goals: 0 [none] 1 2 3 4 5 [significant]

Rate Overall Level of Natural Supports Involvement with the Client/Family: 0 [none] 1 2 3 4 5 [significant]

*Psychiatric** Medications

*Is the member prescribed medication? YES NO If yes, does the member take prescriptions as prescribed? YES NO Did you notify the member’s PCP of this medication? YES NO Is the member’s PCP prescribing psychiatric medications to the member? YES NO Please list all currently prescribed psychiatric medications:

Clinical Indicators Justifying Service Request Select the time period that describes the individual’s most recent occurrence for each indicator that applies. Name of Symptom: Indicate Current Severity: Indicate History of Severity: Risk/Danger to Self/Others Aggressive: Click Here Click Here Fire Setting: Click Here Click Here Assaultive: Click Here Click Here Homicidal Attempt: Click Here Click Here Homicidal ideation: Click Here Click Here Self-Care Deficit: Click Here Click Here Self-Injurious Behavior: Click Here Click Here Sexually Inappropriate Behavior: Click Here Click Here Suicide Attempt: Click Here Click Here Suicidal Ideation: Click Here Click Here Use of Weapons: Click Here Click Here Harm to Animals: Click Here Click Here

Name of Symptom: Indicate Current Severity: Indicate History of Severity: Symptoms and Behaviors Anxiety/Panic: Click Here Click Here Attachment Problems: Click Here Click Here Depressed Mood: Click Here Click Here Dissociative Symptoms: Click Here Click Here Grandiose/Hyper-Religious: Click Here Click Here Hopeless/Helpless: Click Here Click Here Hyperactive: Click Here Click Here Hyper-vigilance: Click Here Click Here Impulsive: Click Here Click Here Insomnia: Click Here Click Here Irritable: Click Here Click Here Lying/Manipulative: Click Here Click Here Obsessions/Compulsions: Click Here Click Here Oppositional Behavior: Click Here Click Here Phobias: Click Here Click Here Property Destruction: Click Here Click Here Psychomotor Retardation: Click Here Click Here Racing Thoughts: Click Here Click Here Running Away: Click Here Click Here Sexually Inappropriate Behavior: Click Here Click Here Separation Problems: Click Here Click Here Social Withdrawal: Click Here Click Here Stealing: Click Here Click Here Trauma-Related Symptoms: Click Here Click Here Truancy: Click Here Click Here Verbal Aggression: Click Here Click Here

Thought, Attention, and Cognition Decreased Concentration: Click Here Click Here Dementia: Click Here Click Here Disorganized Thinking: Click Here Click Here Distractible: Click Here Click Here Hallucinations: Click Here Click Here Paranoid: Click Here Click Here Poor Judgment: Click Here Click Here Thought Disorder: Click Here Click Here

Drugs and Alcohol SA-Related Medical Problems: Click Here Click Here Over-the-counter medications: Click Here Click Here Alcohol Use/Abuse: Click Here Click Here Illicit Drug Use/Abuse: Click Here Click Here Prescription Drug Use/Abuse: Click Here Click Here

Treatment and Service History Select the tool(s) used to screen for co-occurring mental health and substance abuse disorders using the check boxes. Next to each selected tool, indicate if there were one or more YES responses. If the AC-OK is used answer for all 3 domains. If the MHSK III is used, CRAFFT or UNCOPE must also be used.

This Tool Used: AC-OK MH Issues Domain YES NO This Tool Used: AC-OK Trauma Issues Domain YES NO This Tool Used: AC-OK Sub. Abuse Issues Domain YES NO This Tool Used: UNCOPE YES NO This Tool Used: CRAFFT YES NO This Tool Used: MSHF III YES NO Date of Assessment for Co-Occurring Disorders:

Have you communicated with the Member’s PCP to coordinate mental health and physical health care? YES NO N/A

Is member receiving integrated MH/SA services? YES NO

How long has member been receiving this service?

How many times has member been seen by your service within this authorization period?

Number of Inpatient Admissions in the last 12 months: Click Here Number of ER or other crisis episodes in the last 12 months: Click Here Number of years of active mental health treatment: Click Here Number of lifetime homeless episodes: Click Here Number of lifetime jail/prison terms: Click Here Currently on probation/parole or conditional release? Click Here For youth in school, number of suspension in the last 12 months: Click Here For youth under age 18, number of times run away for over 24 hour period:

*Individual Treatment Plan *Describe member’s strengths and skills (Check all that apply): Positive family Network Positive peer support Interest in work/volunteer activity Realistic, positive expectations & goals for future Spiritual/Cultural involvement Natural supports Good Physical health/self-care Stable home setting Involvement in positive activities/interest Good self-awareness/self-understanding Consumer’s strengths are incorporated into the treatment plan Good problem-solving skills/able to seek help when needed Other:

Is the member’s caregiver involved in NO YES forming the individual treatment plan? List those involved with the development of the plan: Member’s expectations of treatment and perception of needs: Family/Caregiver’s expectation of treatment and perception of member’s needs: Disabilities and accommodations required for the delivery of the service: Justification for not addressing needs identified in the assessment: Unmet needs:

Potential barriers to treatment:

Criteria for discharge:

Is substance abuse an issue: NO YES Type of substance: Amount/Frequency of use: Length of use/last use: *Date current treatment plan was developed: *Date next treatment plan is to be developed: Comments: *Treatment Plan Goals Problem Statement:

*Long-Term Goal: *Target Date: Progress since last review: Services to be provided: Frequency of Services: Duration of services: Provider of services:

*Short-Term Goal: *Target Date: Progress since last review: Services to be provided: Frequency of Services: Duration of services:

Additional Required Reporting Data (As Applicable) Current Living Situation: Homeless Shelter or on the streets Own apartment or home Temporarily staying with others Supported apartment Community Residential Facility Nursing Home Residential Treatment Facility (Group Home Arrangement) Residential Crisis Unit Riverview Psychiatric Center Dorothea Dix Psychiatric Center Other Psychiatric Inpatient Unit or Facility Hospitalized for Medical Reasons Incarcerated in a State Prison or County Jail Foster Care Other:

Does the member receive a Rent Subsidy? YES NO Current Vocational/Employment Status: Volunteer Sheltered/Enclave Worker Self-Employed Currently receiving Vocational Rehabilitation Service Competitively Employed Full Time (32 or more hours per week) Competitively Employed Part Time (Less than 32 hours per week) Working with Supports Full-Time (32 or more hours per week) Working with Supports Part Time (Less than 32 hours per week) Not employed – Not looking for work Not employed – Looking for work Other:

Does the member receive Vocational Rehabilitation Services? YES NO Was the member involved with the legal system/police within the last 6 months? YES NO Since the last authorization period, has the member missed a significant number of days of school? YES NO UNKNOWN

Transition Discharge Plan – Check all that apply

*Is Discharge anticipated during the Authorization Period? YES NO Projected Date of Transition/Discharge:

Anticipated Step Down Services: Natural Supports Respite AA/NA Peer Support Outpatient Groups Psychiatric/Medication Management Case Management/CI Section24 Day Treatment ACT/CI Corrections 65M&N Adult Home-Based Services DLSS

Substance Abuse Treatment Crisis Services Crisis Unit Foster Care/Child Welfare Adult Protective Supported Nursing Facility Medical Hospitalization Residential Treatment Other:

Plan for Transition/Discharge:

Additional Information

*Provider Name:

*Provider Electronic Signature:

*Date: