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RULE §306.255Definitions

The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise:

  (1) Adolescent--An individual who is at least 13 years of age, but younger than 18 years of age.

  (2) Adult--An individual who is 18 years of age or older.

  (3) Assessment or reassessment--A systematic process for determining an individual's need for any clinically necessary medical, educational, social, or other services (e.g., taking client history, gathering information from other sources, identifying the needs of the individual, and completing related documentation).

  (4) Business day--Any day except a Saturday, Sunday, or legal holiday listed in the Texas Government Code, §662.021.

  (5) Case manager--An employee who provides MH case management services.

  (6) Child--An individual who is at least three years of age, but younger than 13 years of age.

  (7) CFR--Code of Federal Regulations.

  (8) Community based--A description of the location where routine or intensive case management services are provided (i.e., in an individual's community).

  (9) Community mental health center or CMHC--An entity established in accordance with the Texas Health and Safety Code, §534.001, as a community mental health center or a community mental health and mental retardation center.

  (10) Community resources--People or entities providing services that address the identified needs of individuals receiving MH case management services (e.g., providers of medical care, food, clothing, child care, employment, or housing).

  (11) Community services specialist or CSSP--A staff member who, as of August 31, 2004:

    (A) has received:

      (i) a high school diploma; or

      (ii) a high school equivalency certificate issued in accordance with the law of the issuing state; and

    (B) has had three continuous years of documented full-time experience in the provision of MH case management services; and

    (C) has demonstrated competency in the provision and documentation of MH case management services in accordance with this subchapter and the MH Case Management Billing Guidelines.

  (12) Crisis--A situation in which:

    (A) the individual presents an immediate danger to self or others;

    (B) the individual's mental or physical health is at risk of serious deterioration; or

    (C) an individual believes that he or she presents an immediate danger to self or others or that his or her mental or physical health is at risk of serious deterioration.

  (13) Day--A calendar day, unless otherwise specified.

  (14) Department--Department of State Health Services (DSHS).

  (15) Designee--A person or entity named by the department to act on its behalf.

  (16) Dual relationship--A situation that occurs if a case manager interacts with an individual in more than one capacity, whether it be before, during, or after the professional, social, or business relationship. Dual relationships can occur simultaneously or consecutively.

  (17) Employee--A person who receives a W2 Wage and Tax Statement from a provider.

  (18) Individual--A person seeking or receiving MH case management services.

  (19) Institution for mental diseases or IMD--Based on 42 CFR §435.1009, a hospital, nursing facility, or other institution of more than 16 beds that is primarily engaged in providing psychiatric diagnosis, treatment, or care of individuals with mental illness, including medical attention, nursing care, and related services.

  (20) Intensive case management--A focused effort to coordinate community resources that assist a child or adolescent in gaining access to necessary care and services appropriate to the child's or adolescent's needs. The standards for providing intensive case management services are set forth in §412.407 of this title (relating to MH Case Management Services Standards).

  (21) Intensive case management plan or plan--A written document that is part of the medical record and is developed by a case manager, in collaboration with the individual and the individual's LAR or primary caregiver, that identifies services needed by the individual and sets forth a plan for how the individual may gain access to the identified services.

  (22) Legally authorized representative or LAR--A person authorized by law to act on behalf of an individual with regard to a matter described in this subchapter, including, but not limited to, a parent, guardian, or managing conservator.

  (23) Level of care or LOC--A designation given to the department's standardized packages of mental health services, based on the uniform assessment and the utilization management guidelines, which specify the type, amount, and duration of MH case management services to be provided to an individual.

  (24) Life domains--Areas of life in which a child or adolescent has unmet needs, including, but not limited to safety, health, emotional, psychological, social, educational, cultural, and legal needs.

  (25) Local Behavioral Health Authority (LBHA)--An entity designated as the local behavioral health authority in accordance with Texas Health and Safety Code, §533.0356.

  (26) Medically necessary--A clinical determination made by an LPHA that services:

    (A) are reasonable and necessary for the treatment of a mental health disorder or to improve, maintain, or prevent deterioration of functioning resulting from such a disorder;

    (B) are provided in accordance with accepted standards of practice in behavioral health care;

    (C) are furnished in the most appropriate and least restrictive setting in which services can be safely provided;

    (D) are at the most appropriate level or amount of service that can be safely provided; and

    (E) could not have been omitted without adversely affecting the individual's mental and/or physical health or the quality of care rendered.

  (27) Mental health (MH) case management services--Activities that assist an individual in gaining and coordinating access to necessary care and services appropriate to the individual's needs. Case management activities include assessment, recovery planning, referral and linkage, and monitoring and follow up. Activities may be provided as routine case management or intensive case management.

  (28) Monitoring and follow-up--Activities and contacts that are necessary to ensure that referrals and linkages are effectively implemented and adequately addressing the needs of the individual. The activities and contacts may be with the individual, LAR, primary caregiver, family members, providers, or other people and entities to determine whether services are being furnished, the adequacy of those services, and changes in the needs or status of the individual.

  (29) Primary caregiver--A person 18 years of age or older who:

    (A) has actual care, control, and possession of a child or adolescent; or

    (B) has assumed responsibility for providing shelter and care for an adult.

  (30) Provider--An entity that is:

    (A) a community mental health center that has a contract with the department to provide general revenue-funded MH case management services, Medicaid-funded MH case management services, or both;

    (B) a Local Behavioral Health Authority (LBHA) that has a contract with the department to provide general revenue-funded MH case management services, or a subcontractor of a LBHA.

  (31) Qualified mental health professional-community services or QMHP-CS--A staff member who meets the definition of a QMHP-CS set forth in Subchapter G of this chapter (relating to Mental Health Community Services Standards).

  (32) Recovery--A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.

  (33) Recovery plan or treatment plan--A written plan developed with the individual and, as required, the LAR and a QMHP-CS that specifies the individual's recovery goals, objectives, and strategies/interventions in conjunction with the uniform assessment that guides the recovery process and fosters resiliency as further described in §412.322(e) of this title (relating to Provider Responsibilities for Treatment Planning and Service Authorization) concerning content and timeframe of treatment plan.

  (34) Recovery planning--A systematic process for ensuring the individual's active participation and allowing the LAR, and the primary caregiver and others to develop goals and identify a course of action to respond to the clinically assessed needs. The assessed needs may address medical, social, educational, and other services needed by the individual.

  (35) Referral and linkage--Activities that help link an individual with medical, social, and educational providers, and with other programs and services that are capable of providing needed services (e.g., referrals to providers for needed services and scheduling appointments).

  (36) Routine case management--Services that assist an individual in gaining and coordinating access to necessary care and services appropriate to the individual's needs. The standards for providing routine case management services are set forth in §412.407 of this title.

  (37) Site based--The location where routine case management services are usually provided (i.e., the case manager's place of business).

  (38) Staff member--Provider personnel, including a full-time and part-time employee, contractor, or intern, but excluding a volunteer.

  (39) Strengths based--The concept used in service delivery that identifies, builds on, and enhances the capabilities, knowledge, skills, and assets of the child, adolescent, LAR, or primary caregiver, and family, their community, and other team members. The focus is on increasing functional strengths and assets rather than on the elimination of deficits.

  (40) TAC--Texas Administrative Code.

  (41) Uniform assessment--An assessment adopted by the department that is used for recommending an appropriate level of care (LOC).

  (42) Utilization management guidelines--Guidelines developed by the department that establish the type, amount, and duration of MH case management services for each LOC.

  (43) Wraparound process planning or other department-approved model--A strengths-based course of action involving a child or an adolescent and family, including any additional people identified by the child or adolescent, LAR, primary caregiver, and family, that results in a unique set of community services and natural supports that are individualized for the child or adolescent to achieve a positive set of identified outcomes.

Source Note: The provisions of this §306.255 adopted to be effective February 14, 2013, 38 TexReg 647; amended to be effective March 27, 2017, 42 TexReg 1458; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 469

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