Point32 Therapeutic Mentoring (TM): Massachusetts Products Form

Therapeutic Mentoring (TM) – Massachusetts Products

Therapeutic mentoring provides structured, one-to-one, strength-based support services to youth (under the age of 19) for the purpose of addressing daily living, social and communication needs. Therapeutic mentoring services are provided by a therapeutic mentor in any setting where the youth resides, such as the home (including foster homes and therapeutic foster homes) and other community settings such as a school, childcare centers, respite settings, and other culturally and linguistically appropriate community settings.

Therapeutic mentoring services include supporting, coaching, and training the youth in age-appropriate behaviors, interpersonal communication, functional skill-building, problem solving and conflict resolution. Therapeutic mentoring also includes supporting, coaching and training in relating appropriately to other youth and adults in recreational and social activities. These services help to ensure the youth’s success in navigating various social contexts, learning new skills and making functional progress.

The therapeutic mentor offers supervision of social interactions and engages the youth in discussions about strategies for effective handling of peer interactions. Services are designed to support age-appropriate social functioning or to ameliorate deficits in the youth’s age-appropriate social functioning.

Therapeutic mentoring services are provided by a qualified paraprofessional under the supervision of a licensed clinician. Therapeutic mentoring services must be necessary to achieve goal(s) established in an existing behavioral health treatment plan for youth enrolled in outpatient or in-home therapy or in an ICP for youth enrolled in ICC. Progress toward meeting the identified goal(s) must be documented and reported regularly to the youth’s Clinical Hub.

Clinical Hub

Clinical Hub providers are responsible for coordinating behavioral health services for children and adolescents and collaborating with other service providers (e.g., making regular phone calls to collaterals, holding meetings with the family and other treatment providers, or convening care planning teams for ICC). Clinical Hub services in order of intensity are intensive care coordination (ICC), in-home therapy and outpatient therapy. When more than one Clinical Hub service provider is involved with a family, care coordination is provided by the most intensive service. Clinical Hub providers may refer for services that require a hub (i.e., “hub dependent” services). Hub dependent services include therapeutic mentoring, in-home behavioral services, and family support and training.

Clinical Guideline Coverage Criteria

Admission Criteria

Admission Criteria

The Plan considers therapeutic mentoring services as reasonable and medically when ALL of the following criteria are met:

1. The Youth is under the age of 19; and
2. The Clinical Hub provider’s treatment plan and comprehensive assessment indicates that the youth’s clinical condition warrants this service in order to support age-appropriate social functioning or ameliorate deficits in the youth’s age-appropriate social functioning; and
3. The youth requires education, support, coaching and guidance in age-appropriate behaviors, interpersonal communication, problem-solving and conflict resolution, and relating appropriately to others to address daily living, social and communication needs and to support the youth in a home, foster home, or community setting, or the youth may be at risk for out-of-home placement as a result of the youth’s mental health condition, or requires support in transitioning back to the home, foster home, or community from a congregate care setting; and

4. Outpatient services alone are not sufficient to meet the youth's needs for coaching, support, and education; and

5. Required consent is obtained from the parent or guardian for youths under the age of 18. Once a youth turns 18, they must consent to the services themselves; and
6. The youth is currently engaged in outpatient services, in-home therapy or ICC and the provider or ICC coordinator determines that therapeutic mentoring services can facilitate the attainment of a goal or objective identified in the treatment plan or ICP that pertains to the development of communication skills, social skills and peer relationships.

Continuation Criteria

Continuation Criteria

The Plan considers continuation of therapeutic mentoring services as reasonable and medically necessary when the Clinical Hub has determined that ALL of the following criteria are met:

1. The youth's clinical condition continues to warrant therapeutic mentoring services in order to continue progress toward treatment plan goals; and
2. The youth's treatment does not require a more intensive level of care; and
3. No less intensive level of care would be appropriate; and
4. Care is rendered in a clinically appropriate manner and focused on the youth's behavioral and functional outcomes as described in the treatment plan/ICP; and
5. Progress in relation to specific behavior, symptoms, or impairments is evident and can be described in objective terms, but goals have not yet been achieved, or adjustments in the treatment plan/ICP to address lack of progress are necessary; and
6. The youth is actively participating in the plan of care to the extent possible consistent with his/her condition; and
7. The duplicate statement should be ignored, so ignore this seventh point.

Discharge Criteria

Discharge Criteria

The Plan considers discharge from Therapeutic Mentoring services appropriate for ANY of the following:

1. The youth no longer meets admission criteria for this level of care or meets criteria for a less or more intensive level of care; or
2. The treatment plan/ICP goals and objectives have been substantially met and continued services are not necessary to prevent worsening of the youth's behavioral health condition; or
3. The youth and parent/guardian/caregiver are not engaged in treatment and despite multiple, documented attempts to address engagement, the lack of engagement is of such a degree that it implies withdrawn consent or treatment at this level of care becomes ineffective or unsafe; or
4. Required consent for treatment is withdrawn. Consent is required from the parent or guardian for youths under the age of 18. Once a youth turns 18, they must consent to the services themselves; or
5. The youth is not making progress toward treatment goals and there is no reasonable expectation of progress at this level of care, or continued mentoring is not required to maintain the current level of functioning; or
6. The youth is placed in a hospital, skilled nursing facility, psychiatric residential treatment facility, or other residential treatment setting and is not ready for discharge to a family home environment or a community setting with community-based supports.

Please note that psychosocial, occupational, and cultural and linguistic factors may change the risk assessment and should be considered when making level-of-care decisions

Limitations

Coverage for services is available to children and adolescents that meet the foregoing clinical coverage criteria until the Member’s 19th birthday.

The Plan will continue coverage for services for Members aged 19 and beyond when services are medically necessary and part of an ongoing treatment plan pursuant to the criteria outlined above.

The Plan considers therapeutic mentoring services as not medically necessary for ANY of the following criteria:

1. The youth is no longer authorized to receive outpatient, in-home therapy, or intensive care coordination services through a Clinical Hub
2. The youth displays a pattern of behavior that may pose an imminent risk to harm self or others, or sufficient impairment exists that requires a more intensive service beyond community-based intervention
3. The youth has medical conditions or impairments that would prevent beneficial utilization of services
4. Therapeutic mentoring services are not needed to achieve an identified treatment goal
5. The youth’s primary need is only for observation or for management during sport/physical activity, school, after-school activities or recreation, or for parental respite
6. The service needs identified in the treatment plan/ICP are being fully met by similar services
7. The youth is placed in a residential treatment setting with no plans for return to the home setting.

Codes

The following code(s) are associate with this service: