N.J. Admin. Code § 10:52A-4.3

Current through Register Vol. 56, No. 21, November 4, 2024

Section 10:52A-4.3 - Reimbursable and non-reimbursable APH and PH services

(a) Reimbursable APH services are:

1. Psychiatric services in APH:

i. APH providers shall provide a face-to-face, individual encounter with a psychiatrist or an advanced practice nurse a minimum of every other week for at least 15 minutes in APH. More frequent encounters may be required as deemed clinically necessary during all program hours based upon the beneficiaries' symptomatology and acuity;

2. Treatment services and interventions which assist a beneficiary to resolve an immediate crisis and attain stabilization in order to remain in the community through the support of a less intensive service, which include the following:

i. Individual and group therapy to help identify and manage symptoms and interpersonal problems that contribute to a greater risk of decompensation and relapse. This may include clinical approaches, such as Motivational Interviewing, Dialectical Behavioral Therapy (DBT), Cognitive Behavioral Therapy (CBT) and Cognitive Remediation/Rehabilitation interventions. Staff-to-client ratio in therapy groups shall not exceed 1:10;

ii. Cognitive behavioral skill-building groups focused on affect regulation, stress management and problem solving to promote independence;

iii. Relapse prevention groups to provide psychoeducation and to teach implementation skills; and

iv. Promotion of the beneficiary's commitment to change problematic behaviors and to follow up with aftercare plans;

3. Medication-related services, as needed, which include the following:

i. Medication counseling and education, as provided in 10:37-6.53 and 6.54;

ii. Information regarding, and documentation of, each beneficiary's current medication treatment or therapies;

iii. Procedures by which staff share clinical information regarding medication utilization;

iv. Educating beneficiaries, staff and other caregivers regarding adverse drug reactions, potential side effects and management procedures for responding to crisis situations; and/or

v. Medication education provided within the context of a collaborative and therapeutic relationship. Beneficiaries shall be provided with adequate information in an understandable format regarding a medication's relative effectiveness and safety in order to make an informed decision. Interventions such as medication self-management, behavioral tailoring, simplifying a beneficiary's medication regimen and motivational interviewing assist and support beneficiaries in adhering to their medication regimens. A provider shall specifically review with the beneficiary how medication management issues will impact upon the beneficiary's personal recovery goals and shall be responsible for involving family members whenever possible;

4. Integrated treatment for co-occurring mental health and substance use disorders, which is a distinct clinical approach combining mental health and addiction into a unified, comprehensive and blended philosophy which provides prevention, intervention and treatment techniques which simultaneously address the beneficiary's needs;

5. Assessment and regular monitoring of co-occurring physical health needs to include procurement of medically necessary treatment(s) and services;

6. Beneficiary outreach to facilitate continued participation in the APH program;

7. Integrating the support of family and significant others into a beneficiary's treatment plan;

8. Other planning activities, which may include the development of an advance directive, meeting the requirements of P.L. 2005, c. 233, with specific instructions on what steps need to be taken in the event of a relapse and the development of a personal wellness and recovery action plan;

9. Environmental and safety procedures, which conform with 10:37D-2.5 and 10:37F-2.7;

10. Referral procedures for crisis intervention in the event the beneficiary experiences exacerbation of medical or psychiatric symptoms; and

11. An illness management and recovery program, comprised of a broad set of strategies and activities, which help a beneficiary collaborate with practitioners to identify and pursue personally meaningful recovery goals founded upon a core set of interventions that include: psychoeducation, social skills training, cognitive-behavioral therapy, motivational interviewing and behavioral tailoring and relapse prevention techniques. This is accomplished by helping each beneficiary to develop coping strategies and skills which reduce the beneficiary's susceptibility to the illness, provide assistance and support to effectively manage symptoms to prevent relapse and rehospitalizations and reduce distress to the point where the beneficiary is able to enjoy an improved quality of life. The interventions are intended to be both didactic and practical in nature and can be provided in both group and individual settings. Such services shall be provided directly to beneficiaries and in support of family members or other significant individuals important to the beneficiaries. The services shall include, but are not limited to:

i. Coping skills, adaptive problem solving and social skills training, which teach a beneficiary strategies to self-manage symptoms and personal stress and strengthen life skills and abilities to attain his or her recovery goals;

ii. Psycho-education, which provides factual information, recovery practices, including evidence-based models concerning mental illness which instills hope and emphasizes the potential for recovery. Such services shall be geared toward the beneficiary developing a sense of mastery over his or her illness and life, and shall be effective in reducing relapse and rehospitalizations. The services may also provide support to the beneficiary's family and other members of the beneficiary's social network to help them manage the symptoms and illness of the beneficiary and reduce the level of family and social stress associated with the illness;

iii. Development of a comprehensive relapse prevention plan which offers skills training and individualized support focused on self-management of mental illness and other aspects of recovery, including early recognition, identification and management of symptoms and positive coping strategies and development of supports to reduce the severity and distress of disturbing symptoms. Special attention shall be placed on understanding, recognizing and monitoring of stressors which have triggered return of persistent symptoms in the past. In addition, adaptive problem-solving techniques shall be applied to avoid recurrences in the future;

iv. Dual disorder education which provides basic information to beneficiaries, family members or other significant individuals on the nature and impact of substance use and how it relates to the symptoms and experiences of mental illness and its treatment, as well as upon the attainment of the beneficiary's personal recovery goals;

v. Medication education to be provided within the context of a collaborative and therapeutic relationship. Each beneficiary shall be provided with adequate information in an understandable format regarding each medication's relative effectiveness and safety in order to make an informed decision. Interventions such as medication self-management, behavioral tailoring, simplifying a beneficiary's medication regimen and motivational interviewing assist and support a beneficiary in adhering to a medication regimen. Practitioners shall specifically review with the beneficiary how medication management issues will impact the beneficiary's personal recovery goals and shall be responsible for involving family members whenever possible; and

vi. Wellness activities consistent with the beneficiary's self-identified recovery goals. Wellness activities may address common physical health problems such as tobacco dependency, alcohol use, sedentary lifestyle, lack of physical exercise, overeating or poor nutrition. Other wellness services may address goals such as constructive use of leisure time and fulfilled spirituality and creativity pursuits.

(b) Reimbursable PH services are:

1. Psychiatric services in PH, which include assessment and ongoing treatment supervision.

i. A face-to-face, individual encounter with a psychiatrist or an advanced practice nurse shall be provided for each beneficiary at least once a month in PH. More frequent encounters may be required as deemed clinically necessary during all program hours based upon the beneficiary's symptomatology and acuity;

2. Counseling and case management services, which include evaluation, service planning and personal intervention;

3. Psychoeducational services for beneficiaries and families, which include mental health and medication education;

4. Prevocational services, as appropriate, directed toward maximizing vocational potential, including work readiness, prevocational experiences, prevocational training and counseling, prevocational assessment and planning. Prevocational services are an array of strategies and interventions that assist the beneficiary in acquiring general work behaviors, attitudes and skills in response to the interests and needs of beneficiaries who are considering, or intending to take on, roles which may be used in other life domains.

i. Prevocational intervention or strategies selected shall be based upon an assessment of the beneficiary's interest, needs, skills and supports and reflected in the beneficiary's Individualized Recovery Plan.

ii. Prevocational activities include, but are not limited to:

(1) Understanding and choosing work settings;

(2) Gathering and researching job information;

(3) Clarifying occupational values and interests;

(4) Defining work preferences;

(5) Identifying personal work criteria;

(6) Exploring barriers to working;

(7) Identifying and defining critical work skills;

(8) Researching personal work supports and resources;

(9) Identifying psychiatric illness management strategies related to working;

(10) Simulated work activities, such as work units to address work hardening, concentration, attendance and other skills; and

(11) Learning methods to respond to criticism, negotiating for needs, dealing with interpersonal issues, and adherence to medication requirements.

iii. Therapeutic subcontract work may be provided within the context of partial hospitalization as prevocational therapy, if already provided by the provider's program as of October 1, 2006.

(1) Therapeutic subcontract work activity shall consist of the production, assembly or packing tasks for compensation obtained by the organization under a contract with a vendor for which individuals with disabilities performing the tasks are paid under a wage and hour certificate, which meets all Federal requirements, typically less than minimum wage.

(2) The beneficiary's Individualized Recovery Plan shall stipulate that the therapeutic subcontract work is a form of intervention intended to address the beneficiary as identified in the beneficiary's assessment.

(3) The therapeutic subcontract work shall be facilitated by a qualified mental health services worker.

(4) The therapeutic subcontract work activity shall be performed within the line of sight of the qualified mental health service worker.

(5) The staff to consumer ratio shall not exceed a ratio of 1:12 qualified mental health services worker to consumer;

5. Community integration services, such as independent living skills training and goal-oriented cultural activities;

6. Engagement strategy services designed to connect with a beneficiary over time in order to develop a commitment on the beneficiary's part to enter into therapeutic relationships supportive of the beneficiary's recovery. This service may include, but is not limited to, activities, such as initial contacts with potential program participants, as well as continued efforts to engage individuals to participate in program services;

7. Activities designed to assist a beneficiary to identify, achieve and retain personally meaningful life goals over time which help the person resume normal functioning in valued life roles in self-chosen community environments. Examples of such goals include, but are not limited to, returning to work or school, returning to adult care-giving or parenting roles, resuming roles as a spouse or significant other, becoming a member of a religious community or becoming a neighbor;

8. An illness management and recovery program, comprised of a broad set of strategies and activities which help a beneficiary collaborate with practitioners to identify and pursue personally meaningful recovery goals founded upon a core set of interventions which include: psycho-education, social skills training, cognitive-behavioral therapy, motivational interviewing and behavioral tailoring, and relapse prevention techniques. This is accomplished by helping each beneficiary to develop coping strategies and skills which reduce the beneficiary's susceptibility to the illness, provide assistance and support to effectively manage symptoms to prevent relapse and rehospitalizations and reduce distress to the point where the beneficiary is able to enjoy an improved quality of life. They are intended to be both didactic and practical in nature and can be provided in both group and individual settings. Such services shall be provided directly to beneficiaries and in support of family members or other significant individuals important to the beneficiaries. The services shall include, but are not limited to:

ii. Psycho-education which provides factual information, recovery practices, including evidence-based models concerning mental illness, which instills hope and emphasizes the potential for recovery. Such services shall be geared toward the beneficiary developing a sense of mastery over his or her illness and life, and shall be effective in reducing relapse and rehospitalizations. It may also provide support to the beneficiary's family and other members of the beneficiary's social network to help them manage the symptoms and illness of the beneficiary and reduce the level of family and social stress associated with the illness;

iv. Dual disorder education, which provides basic information to beneficiaries, family members or other significant individuals on the nature and impact of substance use and how it relates to the symptoms and experiences of mental illness and its treatment, as well as upon the attainment of the beneficiary's personal recovery goals;

v. Medication education to be provided within the context of a collaborative and therapeutic relationship. Each beneficiary shall be provided with adequate information in an understandable format regarding each medication's relative effectiveness and safety in order to make an informed decision. Interventions such as medication self-management, behavioral tailoring, simplifying a beneficiary's medication regimen and motivational interviewing assist and support a beneficiary in adhering to a medication regimen. Practitioners shall specifically review with the beneficiary how medication management issues will impact a beneficiary's personal recovery goals and shall be responsible for involving family members whenever possible; and

9. Skill development needed for beneficiary-chosen community environments, facilitating beneficiary-directed recovery and re-integration into community living, learning, working and social roles by developing critical competencies and skills. Skill development may be accomplished through either individual or group instruction; however, the direct staff-to-beneficiary ratio in group activities shall not exceed 1:12. Examples include, but are not limited to, developing:

i. Cognitive skills such as researching and recording information, decision making, identifying preferences and values, selecting clothing, interviewing, scheduling appointments, budgeting, personal nutrition planning, etc.;

ii. Physical skills such as showering, grooming, cooking, cleaning personal space, shopping, taking public transportation, parenting etc.; and

iii. Emotional skills such as negotiating, communicating, asking for help, avoiding risks to sobriety, greeting others, conversing, identifying psychiatric cues, planning for psychiatric emergencies, etc.;

10. Medication-related services, as needed, which include the following:

i. Medication counseling and education, as defined in 10:37-6.53 and 6.54;

ii. Knowledge and documentation of each beneficiary's current medication treatment and therapies;

iii. Providing a mechanism for staff to share clinical information regarding medication utilization; and

iv. Education of beneficiaries, staff and other caregivers regarding adverse drug reactions, potential side effects and established procedures for responding to crisis situations;

11. Goal-oriented verbal counseling, which may include individual, group and family modalities to address the emotional, cognitive and behavioral symptoms of mental health illness or to engage, motivate, stabilize and address related effects on role functioning including beneficiaries with a co-occurring mental health and substance use disorder. Goal-oriented verbal counseling may also include motivational interviewing, connecting skills and cognitive behavioral therapy;

12. Age-appropriate learning activities, which are directly tied to the learning of daily living or other community-integration competencies such as financial literacy, basic computer literacy and recognition of directions and safety warnings. Such basic computing, reading or writing skills are considered incidental and not student education;

13. Community integration services, which include independent living skills training, interpersonal skills such as greeting, talking about impersonal topics, conversing, learning about available community cultural opportunities, practicing social interaction, and spiritual and cultural activities;

14. Psychiatric services, which include assessment and ongoing treatment supervision;

15. Other planning activities including the development of an advance directive, which meets the requirements of P.L. 2005, c. 233, with specific instructions on the steps to be taken in the event of a relapse and the development of a personal wellness and recovery action plan (WRAP); and

16. Integrated treatment for co-occurring mental health and substance use disorders, which is a distinct clinical approach combining mental health and addiction into a unified, comprehensive and blended philosophy which provides prevention, intervention and treatment techniques which simultaneously address the beneficiary's needs.

(c) Services which shall not be reimbursed shall include:

1. Vocational services, such as technical occupational skills training, college preparation, individualized job development and marketing to employers;

2. Student education, including preparation of school-assigned class work or homework;

3. Off-site services and activities, unless conducted in accordance with the provisions of this chapter;

4. Transportation, which is not a component of active programming; and

5. Breaks or mealtimes.

(d) Reimbursement for APH and PH services shall be made pursuant to 10:52-4.3.

N.J. Admin. Code § 10:52A-4.3

Amended by R.2012 d.050, effective 3/5/2012.
See: 43 N.J.R. 2112(a), 44 N.J.R. 594(a).
In (b)4iii(5) and (b)9, substituted "1:12" for "1:10".