Nepotism No employee shall be awarded a position where he/she is to be directly supervised by a member of his/her immediate family. “
Behavioral Health Services – Mental Health and Substance Use Disorder Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible Outpatient or intermediate careservices* - See Covered Healthcare Services: Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible 40% - After deductible Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. 0% - After deductible 40% - After deductible Methadone maintenance treatment - one copayment per seven-day period of treatment. 0% - After deductible 40% - After deductible Cardiac Rehabilitation Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible 40% - After deductible Chiropractic Services In a physician's office - limited to 12 visits per plan year. 0% - After deductible 40% - After deductible Dental Services - Accidental Injury (Emergency) Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Dental Services- Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Dialysis Services Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchasedat licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider. Early Intervention Services (EIS) Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% - After deductible The level of coverage is the same as network provider. Education - Asthma Asthma management 0% - After deductible 40% - After deductible Emergency Room Services Hospital emergency room 0% - After deductible The level of coverage is the same as network provider.
Clinical Management for Behavioral Health Services (CMBHS) System The CMBHS is the official record of documentation by System Agency. Grantee shall:
Health Screening The Contractor shall conduct a Health Needs Screen (HNS) for new members that enroll in the Contractor’s plan. The HNS will be used to identify the member’s physical and/or behavioral health care needs, special health care needs, as well as the need for disease management, care management and/or case management services set forth in Section 3.8. The HNS may be conducted in person, by phone, online or by mail. The Contractor shall use the standard health screening tool developed by OMPP, i.e., the Health Needs Screening Tool, but is permitted to supplement the OMPP Health Needs Screening Tool with additional questions developed by the Contractor. Any additions to the OMPP Health Needs Screening Tool shall be approved by OMPP. The HNS shall be conducted within ninety (90) calendar days of the Contractor’s receipt of a new member’s fully eligible file from the State. The Contractor is encouraged to conduct the HNS at the same time it assists the member in making a PMP selection. The Contractor shall also be required to conduct a subsequent health screening or comprehensive health assessment if a member’s health care status is determined to have changed since the original screening, such as evidence of overutilization of health care services as identified through such methods as claims review. Non-clinical staff may conduct the HNS. The results of the HNS shall be transferred to OMPP in the form and manner set forth by OMPP. As part of this contract, the Contractor shall not be required to conduct HNS for members enrolled in the Contractor’s plan prior to January 1, 2017 unless a change in the member’s health care status indicates the need to conduct a health screening. For purposes of the HNS requirement, new members are defined as members that have not been enrolled in the Contractor’s plan in the previous twelve (12) months. Data from the HNS or NOP form, current medications and self-reported medical conditions will be used to develop stratification levels for members in Hoosier Healthwise. The Contractor may use its own proprietary stratification methodology to determine which members should be referred to specific care coordination services ranging from disease management to complex case management. OMPP shall apply its own stratification methodology which may, in future years, be used to link stratification level to the per member per month capitation rate. The initial HNS shall be followed by a detailed Comprehensive Health Assessment Tool (CHAT) by a health care professional when a member is identified through the HNS as having a special health care need, as set forth in Section 4.2.4, or when there is a need to follow up on problem areas found in the initial HNS. The detailed CHAT may include, but is not limited to, discussion with the member, a review of the member’s claims history and/or contact with the member’s family or health care providers. These interactions shall be documented and shall be available for review by OMPP. The Contractor shall keep up-to-date records of all members found to have special health care needs based on the initial screening, including documentation of the follow-up detailed CHAT and contacts with the member, their family or health care providers.
Behavioral Health Services Behavioral health services include the evaluation, management, and treatment for a mental health or substance use disorder condition. For the purpose of this plan, substance use disorder does not include addiction to or abuse of tobacco and/or caffeine. Mental health or substance use disorders are those that are listed in the most updated volume of either: • the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association; or • the International Classification of Disease Manual (ICD) published by the World Health Organization. This plan provides parity in benefits for behavioral healthcare services. Please see Section 10 for additional information regarding behavioral healthcare parity. Inpatient This plan covers behavioral health services if you are inpatient at a general or specialty hospital. See Inpatient Services in Section 3 for additional information. Residential Treatment Facility This plan covers services at behavioral health residential treatment facilities, which provide: • clinical treatment; • medication evaluation management; and • 24-hour on site availability of health professional staff, as required by licensing regulations. Intermediate Care Services This plan covers intermediate care services, which are facility-based programs that are: • more intensive than traditional outpatient services; • less intensive than 24-hour inpatient hospital or residential treatment facility services; and • used as a step down from a higher level of care; or • used a step-up from standard care level of care. Intermediate care services include the following: • Partial Hospital Program (PHP) – PHPs are structured and medically supervised day, evening, or nighttime treatment programs providing individualized treatment plans. A PHP typically runs for five hours a day, five days per week. • Intensive Outpatient Program (IOP) – An IOP provides substantial clinical support for patients who are either in transition from a higher level of care or at risk for admission to a higher level of care. An IOP typically runs for three hours per day, three days per week.
Mental Health Services This agreement covers medically necessary services for the treatment of mental health disorders in a general or specialty hospital or outpatient facilities that are: • reviewed and approved by us; and • licensed under the laws of the State of Rhode Island or by the state in which the facility is located as a general or specialty hospital or outpatient facility. We review network and non-network programs, hospitals and inpatient facilities, and the specific services provided to decide whether a preauthorization, hospital or inpatient facility, or specific services rendered meets our program requirements, content and criteria. If our program content and criteria are not met, the services are not covered under this agreement. Our program content and criteria are defined below.
Behavioral Health Behavioral health services, with the exception of Medicaid Rehabilitation Option (MRO) and 1915(i) services, are a covered benefit under the Hoosier Healthwise program. The Contractor shall be responsible for managing and reimbursing all such services in accordance with the requirements in this section. In furnishing behavioral health benefits, including any applicable utilization restrictions, the Contractor shall comply with the Mental Health Parity and Additions Equity Act (MHPAEA). This includes, but is not limited to: Ensuring medical management techniques applied to mental health or substance use disorder benefits are comparable to and applied no more stringently than the medical management techniques that are applied to medical and surgical benefits. Ensuring compliance with MHPAEA for any benefits offered by the Contractor to members beyond those otherwise specified in this Scope of Work. Making the criteria for medical necessity determinations for mental health or substance use disorder benefits available to any current or potential members, or contracting provider upon request. Providing the reason for any denial of reimbursement or payment with respect to mental health or substance use disorder benefits to members. Providing out-of-network coverage for mental health or substance use disorder benefits when made available for medical and surgical benefits. The Contractor shall assure that behavioral health services are integrated with physical care services, and that behavioral health services are provided as part of the treatment continuum of care. The Contractor shall develop protocols to: Provide care that addresses the needs of members in an integrated way, with attention to the physical health and chronic disease contributions to behavioral health; Provide a written plan and evidence of ongoing, increased communication between the PMP, the Contractor and the behavioral health care provider; and Coordinate management of utilization of behavioral health care services with MRO and 1915(i) services and services for physical health.
Digital Health The HSP agrees to:
Community Mental Health Center Services Assertive Community Treatment Staffing Full Time Equivalents Community Mental Health Center March 2021 December 2020 Nurse Masters Level Clinician/or Functional Support Worker Peer Specialist Total (Excluding Psychiatry) Psychiatrist/Nurse Practitioner Total (Excluding Psychiatry) Psychiatrist/Nurse Practitioner 01 Northern Human Services - Wolfeboro 1.00 0.00 0.00 0.57 6.81 0.27 8.27 0.25 01 Northern Human Services - Berlin 0.34 0.31 0.00 0.00 3.94 0.14 4.17 0.14 01 Northern Human Services - Littleton 0.00 0.14 0.00 0.00 3.28 0.29 3.31 0.29 02 West Central Behavioral Health 0.60 1.00 0.00 0.00 5.40 0.30 5.90 0.30 03 Lakes Region Mental Health Center 1.00 1.00 0.00 1.00 5.00 0.40 7.00 0.38 04 Riverbend Community Mental Health Center 0.50 1.00 6.90 1.00 10.40 0.50 10.50 0.50 05 Monadnock Family Services 1.91 2.53 0.00 1.12 11.17 0.66 10.32 0.62 06 Greater Nashua Mental Health 1 1.00 1.00 3.00 1.00 7.65 0.15 8.50 0.15 06 Greater Nashua Mental Health 2 1.00 1.00 4.00 1.00 8.65 0.15 8.50 0.15 07 Mental Health Center of Greater Manchester-CTT 1.33 10.64 2.00 0.00 19.95 1.17 21.61 1.21 07 Mental Health Center of Greater Manchester-MCST 1.33 9.31 3.33 1.33 19.95 1.17 25.27 1.21 08 Seacoast Mental Health Center 1.00 1.10 5.00 1.00 10.10 0.60 10.10 0.60 09 Community Partners 0.50 0.00 3.40 0.88 7.28 0.70 7.41 0.70 10 Center for Life Management 1.00 0.00 2.28 1.00 6.71 0.46 6.57 0.46 Total 12.51 29.03 29.91 9.33 126.29 6.96 137.43 6.96 2b. Community Mental Health Center Services: Assertive Community Treatment Staffing Competencies Community Mental Health Center Substance Use Disorder Treatment Housing Assistance Supported Employment March 2021 December 2020 March 2021 December 2020 March 2021 December 2020 01 Northern Human Services - Wolfeboro 1.27 1.27 5.81 6.30 0.00 0.40 01 Northern Human Services - Berlin 0.74 0.74 3.29 3.29 0.00 0.23 01 Northern Human Services - Littleton 1.43 1.29 2.14 2.14 1.00 1.00 02 West Central Behavioral Health 0.20 0.20 4.00 0.40 0.60 0.60 03 Lakes Region Mental Health Center 1.00 3.00 5.00 7.00 2.00 2.00 04 Riverbend Community Mental Health Center 0.50 0.50 9.40 9.50 0.50 0.50 05 Monadnock Family Services 1.69 1.62 4.56 4.48 0.95 1.18 06 Greater Nashua Mental Health 1 6.15 7.15 5.50 6.50 1.50 1.50 06 Greater Nashua Mental Health 2 5.15 5.15 6.50 6.50 0.50 0.50 07 Mental Health Center of Greater Manchester-CCT 14.47 15.84 13.96 15.62 2.66 2.66 07 Mental Health Center of Greater Manchester-MCST 6.49 7.86 15.29 19.28 1.33 2.66 08 Seacoast Mental Health Center 2.00 2.00 5.00 5.00 1.00 1.00 09 Community Partners 1.20 1.20 4.50 4.50 1.00 1.00 10 Center for Life Management 2.14 2.14 5.42 5.28 0.29 0.29 Total 44.43 49.96 90.37 99.39 13.33 15.52 Revisions to Prior Period: None. Data Source: Bureau of Mental Health CMHC ACT Staffing Census Based on CMHC self-report. Notes: Data compiled 04/26/2021. For 2b: the Staff Competency values reflect the sum of FTEs trained to provide each service type. These numbers are not a reflection of the services delivered, but rather the quantity of staff available to provide each service. If staff are trained to provide multiple service types, their entire FTE value is credited to each service type.
Within Southern DHB External to Southern DHB Nurse Manager • Relevant associated groups, local and regional • Service Manager • Healthcare providers • Unit team managers • Healthcare patients/consumer • Clinical Charge Nurse • National Speciality groups • Clinical Leaders • NZNO, PSA and other relevant professional colleges of nursing and midwifery • All Nursing and Midwifery Staff • Nursing Council/Midwifery council • Allied Health Staff • Nurse Educators • Medical Staff • Clinical Support Staff • Infection Prevention and Control • Occupational Health & Safety PERSON SPECIFICATION The expertise required for a person to be fully competent in the role. Position specific competencies: ESSENTIAL DESIRABLE Education and Qualifications (or equivalent level of learning) • Be registered with the Nursing Council of New Zealand as a registered Nurse • Hold a current Nursing Council of New Zealand annual practising certificate • Working towards Post graduate qualifications at a minimum of a Diploma or/and a masters degree • Advanced learning and contemporary knowledge in area of specialist practice. • Experience • Experience and credibility with the health care team as a professional resource in speciality/practice area • Networking effectively in area of specialty/ practice. • Demonstrated ability to articulate evidence based nursing advice to a Multidisciplinary Team. • Minimum of 3 years practice within the defined scope of clinical speciality/practice Knowledge and Skills • Exercise independent nursing judgement, apply advanced assessment skills, initiate appropriate clinical interventions, evaluate outcomes, advise others and provide sound rationale for actions in area of speciality/practice. • Work independently and in the interdisciplinary team, using evidence based evidence and international best practice, in area of speciality. • Initiate health promotion activities to encourage productive health behaviours and xxxxxx the strengths and potential of patients/consumer and staff. • Be a professional leader and role model, with proven ability to inspire, motivate and develop others, in area of speciality. • Be champions for, and promote the profession of nursing. • Current issues for nursing and health in NZ and international context. • Current government policies, codes, guidelines, and legislation impacting on area of speciality. • Current nursing professional standards and codes. • Southern DHB current vision, goals and objectives. • Principles of the Treaty of Waitangi and biculturalism. Personal Qualities A reasonable level of fitness is required to cope with the demanding physical requirements of the job. The following denote the key physical requirements for the position: standing, walking, bending, sitting, stairs, simple grasping, fine manipulation, operating machinery / equipment, lifting, overhead reaching, carrying, pushing / pulling, twisting, climbing / balancing, crouching / squatting, manual handling of people, other reaching, and ability to participate in personal restraint if required. KEY RESULT AREAS: Key Accountabilities: Example of successful delivery of duties and responsibilities Leadership Works collaboratively to achieve the organisation, nursing and specialty vision and values, and promotes quality patient outcomes. Inspires, motivates and encourages nurses to initiate and maintain best practice in their specialty area. Takes the leadership role through both direct and indirect patients/consumer care delivery. Provides senior nursing leadership for the specialty service and consultation to a broad range of hospital, community and professional groups to achieve positive outcomes for patient or population group. Supports a culture of evaluation and the ongoing quality improvement of nursing practice. Is actively involved in professional activities such as research, scholarship and policy development at both a local and national level. Staff are encouraged and supported in their work as it relates to the area of speciality practice. Xxxxxxx and participates in peer review processes, case review and reflective practice. Team members are motivated and stimulated. Evaluates current practice, identifies deficits/needs and introduces quality measures. Participates actively in team meetings. Leads system change to improve health outcomes through evidence based practice. Participates in clinical governance activities Works closely with team members from a wide range of clinical disciplines, helping to create a productive responsive patient focused team that is able to deliver cost effective quality care. Represents the specialty nursing perspective. Involvement with workforce development and succession planning for the service from a nursing perspective. Employs and models transformational leadership style and coaches nurses to develop own leadership skills. Clinical Practice Promotes and role models expert nursing care either directly or indirectly, especially for those with complex needs. Provides expert nursing knowledge in the management of patients/consumer care within a defined area of speciality practice, working with the patient, family/whanau or other health professionals to provide timely nursing care to optimise outcomes. Exercises independent nursing judgement, applies advanced assessment skills, initiates appropriate clinical interventions, evaluates outcomes, advises others and provides sound rationale for actions in area of speciality Prescribes advanced evidenced based nursing therapeutics, pharmacological/ non- pharmacological interventions, diagnostic measures, equipment, procedures, and treatments to meet the needs of patients/consumer, families and groups, in accordance with professional preparation, institutional policies and scope of practice. Acts as a mentor, guides and supports others in the speciality in their assessment, clinical decision making, implementation, evaluation and documentation of care. Facilitates/initiates inter service collaboration and promotes integrated care between secondary and primary services to improve patient care. Undertakes extended interventions as authorised by NCNZ Networks nationally and internationally to identify and implement nursing advances and changes in speciality practice. Maintains a significant presence in the clinical area as a resource, role model, mentor and advocate. Facilitates / initiates inter-service collaboration to improve patient care Provides input into the development of care co-ordination initiatives Professional portfolio maintained PDRP at level 4. Meets Nursing Council NZ requirements for APC Clinical Practice Works with nursing staff to continuously improve nursing practice and patient/consumer outcomes. Role models expert evidenced based clinical practice, is seen as highly effective, progressive and knowledgeable. Provides leadership, role models and guides others in nursing practice that is evidenced based and consistent with the principles of the Treaty of Waitangi. Gains support for changes to nursing practice that are based on: • quality improvement activity reports • patient/consumer feedback • contractual/ legislative changes • treatment changes current evidence based best practice. Participates in auditing nursing quality standards, policies, procedures and guidelines and developing action plans relevant to speciality. Clinical Practice Articulates the ethical, cultural and statutory requirements of practice and initiates / responds to changes from the internal and external environment. Provides input into, and helps interpret requirements of new legislation /guidelines. Supports clinicians in identifying ethical dilemmas working through a decision making framework. Attends and provides input into and feedback from relevant committees. Nursing specialty submissions are made in the development of relevant organisational and national policies. Actively manages risk. Assess the quality of nursing practice in the clinical setting. Collaborates on any changes required. To demonstrate effective interpersonal relationship skills [Description where applicable] Establishes, maintains and concludes therapeutic interpersonal relationships with patient/consumer. Practices nursing in a negotiated partnership with the patient/consumer and family/whanau where and when possible. Communicates effectively with patients/consumer and family/whanau and members of the health care team. Maintains privacy and confidentiality in accordance with HIP Code, DHB policies and procedures etc. Communicates in an appropriate and professional manner, verbal and written. Privacy Act, Informed Consent and Code of Rights adhered to. Abides by NCNZ Code of Conduct and Professional Boundaries guidelines. To participate in inter-professional health care Leads nursing and interdisciplinary groups in designing and implementing innovative, cost effective patient care and evidence-based change Provides a primary point of contact within the speciality for patients/consumer and health professionals Initiates referrals to other members of the health care team in a timely manner. Evaluates results of interventions using recommended criteria, revises management/treatment and initiates timely referral/care with relevant services/agencies Is a competent consultant for interdisciplinary client base Contributes to research and the dissemination of findings where possible Contributes to the development of interdisciplinary standards of practice and evidence-based guidelines Demonstrate leadership in establishing collaborative relationships within and across departments, hospitals, primary and secondary health to promote optimal patient/consumer health and safety and continuity of care. Initiates timely referrals to other services in a timely and thorough manner. Engages in team and MDT meetings as appropriates. Initiate appropriate audit processes. Consistently participates/leads multi-disciplinary team meetings and family conferences, representing the nursing perspective of patient/consumer needs, and enacting outcomes appropriately. Leads in activities which monitor/audit delivery of quality patient care e.g. Certification processes, and current or retrospective nursing audits. Engages in submission processes. Education Assists in providing for the educational needs of staff within the specialised area of practice. Collaborates in the development of education programmes related to the area of speciality knowledge and skill. Develops professional networks Locally, Nationally and Internationally to maintain current knowledge of trends and developments in specialty area. Participates in the educational plan for the speciality. Participates in nursing forums where relevant to area of practice Colleagues are informed of relevant nursing professional trends and issues. Participates in collaborative educational networks to meet professional and service needs. Shares specialist knowledge and skills in formal and informal education activities and ensures that nurses are supported in their development of culturally safe practice. Assists in evaluating educational programmes offered, that focus on the area of speciality practice, to ensure content is evidence based and reflective of current thinking. Nurses are kept informed of relevant evidence based practice and issues, including ethical issues. Education Provides educational support for healthcare providers and patients. Disseminates specialty knowledge at both a Local and National/International level to ensure healthcare providers and consumers are informed about the service CNSs provide, hence facilitating access to the speciality support they require. Shares specialist knowledge and skills in formal and informal education activities and ensures that nurses are supported in their development of culturally safe practice. Acts as a resource person for patients/consumer and health professionals. Collaborates with Nurse Educators and line managers to identify staff training needs and to develop an educational plan to address these needs. Assists in the orientation and preceptor ship of new nurses and student nurses. Provides clinical guidance and mentoring to nursing and allied health colleagues. Teaching sessions are provided for health care providers e.g. general practitioners, practice nurses, staff in rural areas etc, as relevant to area of speciality. Education programmes are developed for patients/consumers to assist them to achieve their best clinical outcomes. This may include health promotion / wellness activities. Assists in the compilation of resource material for educational purposes for patients/consumer, families and healthcare professionals updating as required, to promote the sharing of current evidence-based information. Research Promotes quality nursing care through research-based practice Relevant nursing and related research is read, critiqued and discussed as a means of supporting the development of quality nursing practice. Participates in conferences relevant to area of speciality, as agreed line manager. Patients/consumer research which challenges practice at local and national forums. Information is communicated to staff within Southern DHB, to maximise the benefit for the patient/consumer and organisation. Research Role models the application of evidence based best practice principles in own practice, and assist others in research related activities. Demonstrates ability to interpret and implement research findings relevant to area of speciality practice. Provides research based clinical management options for complex clinical situations / issues. There is evidence of staff participation in research related activities where appropriate and authorised.