Adult Medi-Cal Mental Health Severity Analysis

San Diego County Adult Medi-Cal Mental Health Severity Analysis Mental Health Plan will follow Medical Necessity Criteria for Medi-Cal Specialty Mental Health Services described in Title 9, CCR

(0) Element Mild (1) Moderate (2) Severe (3) N/A Risk (suicidal/violent, Passive ideation or fantasy— Passive ideation or low Recent or current active ideation, high risk behavior, no danger to self/danger to level active with DTS/DTO intent or plan catastrophic illness/loss, others (DTS/DTO) history history Poor impulse control Good impulse control Rare loss of impulse Violence related arrests, jail or prison criminogenic behavior, Minimal criminal time impulsivity, insight, ego background, control Poor insight discordance) Good insight Mid-level nonviolent Ego syntonic (refers to instincts, Ego dystonic (refers to arrests, brief jail time ideas, and behaviors that are viewed thoughts, impulses, and Fair insight as acceptable to one’s self, are behaviors that are viewed as Ego dystonic compatible with one’s values and unacceptable, distressing, or ways of thinking, or are consistent inconsistent with one’s self- with one’s fundamental personality or concept) beliefs) Clinical Complexity Adjustment reaction Schizophrenia, major mood or Schizophrenia, major mood or (serious & persistent mental Minor anxiety disorder – stable on anxiety disorder, recent illness vs situational/reactive, depression/anxiety medications, baseline instability or worsening function, recovery status, functional & Grief, job loss, marital function, sustained recovery precarious recovery, cognitive cognitive impairment, Prior history of effective distress, relationship treatment, uncomplicated impairment treatment resistance, difficulty Recent/repeated hospitals medication complexity, management frequent hospitalization, co- No cognitive impairment Minimal cognitive impairment AOD dependence occurring medical and No prior serious mental No recent hospitalizations Prior history of treatment alcohol or drug disorder illness (SMI) history AOD misuse (e.g., multiple resistance or complexity (e.g.. (AOD)) Limited AOD use emergency room visits at polypharmacy) different hospitals) Life Circumstances Emotional distress Intermittent emotional Persistent emotional distress a (biopsychosocial assessment, arising in the course of distress as a manifestation of manifestation of chronic mental availability of resources, normal life stresses a mental illness which is illness environmental stressors, Adequately resourced & worsened by life stresses Relies on behavioral health Limited resources & support family/social/faith-based supported system for resources & support support, resilience) Strained resilience Resilient Limited resilience Benefit of Integrated High (1) Medium (2) Low (3) Care (optimal for stable Already established, High medical, low behavioral Already established (or pending) patients with co-occurring effective care in primary care with County provider for mild to moderate physical and care setting for chronic High behavioral, low complex SMI mental illness, limited stable medical + co- medical Relies on behavioral health transportation or unique occurring mild mental system for resources & support clinical/cultural needs not well suited for split care) illness/emotional distress Low recovery Total: Tier 1 (0-4) Tier 2 (5-8) Tier 3 (9-12) Referrals Augmented Primary Care Health Plan Network: County Mental Health Plan Provider (PCP)-Impact -FQHC (MHP): Health Plan Network: -Health Plan BH Network -County Clinics -Federally Qualified -FQHC Health Center (FQHC) -Organizational Provider -Health Plan Behavioral -Optum Fee-for-Service (FFS) Health (BH) Network Provider

1/2015 Care1st Health Plan Community Health Health Net (MHN) Kaiser Permanente Molina Healthcare (855) 321-2211 Group (888) 426-0030 (877) 496-0450 (888) 665-4621 Care1st.com (800) 404-3332 Healthnet.com KP.org MolinaHealthcare.com Chgsd.com

SAN DIEGO COUNTY MEDI-CAL MANAGED CARE HEALTH PLANS

1/2015