Specifications include, but are not limited to: Establish Mobile PRTF/ CABHH transition team(s) for youth currently admitted to PRTF, CABHH or inpatient psychiatric care in need of transition to Community or otherwise medically necessary level of care. Teams will be expected to provide transition services to all eligible youth residing in Minnesota regardless of geographic location. Mobile transition team staff complement may include, but is not limited to, the following core components: Certified Family Peer Specialist Duties to include facilitating family engagement, family empowerment and participation in transition planning Transition Care Coordinator Transition Care Coordinators must have training and background in child development and children’s mental health. They will work with the youth’s treatment team and other members of the support network to facilitate development of an outcome-oriented transition plan. Transition Care Coordinators will not duplicate any work of an assigned Children’s Mental Health Targeted Case Manager (CMH-TCM). If a CMH-TCM is assigned to a youth transitioning from PRTF or CABHH, the transition case manager will collaborate to enhance efforts towards aftercare and discharge planning. An MHM Transition Coordinator would not be an allowable service while a youth is engaged in Mobile PRTF. Vocations Skills Trainer The Vocations Skills Coordinator focuses on hands-on learning while offering opportunities and exposure to a variety of skills within a career-focused environment. Basic Needs Coordinator This role will collaborate with the child’s case manager (if applicable), to help with the following: Provide services such as connecting families with Housing, Food, Health Care or other needs as identified. Services may also include connection to supported employment services if case management is not involved. *Mobile transition teams may also include clinical supervision from a licensed mental health provider but is not required. Services will be trauma-informed, person-centered, and culturally responsive. Culturally responsive means to, “Provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs.” Mobile transition teams will utilize promising and evidence-based practices. A promising service or practice is a practice that has some research demonstrating effectiveness for at least one outcome of interest. To qualify, the promising practice needs to have at least one qualifying evaluation that uses an experimental or quasi-experimental design. Evidence-based practices have a high level of research demonstrating effectiveness. The Minnesota Management and Budget Office maintains the Minnesota Inventory which is a list of services that meet the promising and evidence-based criteria. Examples of evidence-based practices may include but are not limited to Collaborative Problem Solving (CPS), Motivational Interviewing (MI), or other short-term solution-focused and outcome-oriented interventions. Mobile transition teams will utilize Person-Centered Practices to support integration into the Community to the greatest extent possible. Eligible recipients of PRTF mobile transition team services are any Medicaid enrolled member currently admitted to a PRTF or CABHH up to the age of 21 (eligible recipients may be 22 if admitted to PRTF by age of 21). Eligibility for lesser HCBS and MHM services may be established through MnCHOICES assessment. Key PRTF benefit eligibility requirements for children are: Other Community based (less restrictive) mental health services have been exhausted and/or cannot provide the level of care needed. Psychiatric residential treatment is required to improve the individual’s condition or prevent further regression so that services will no longer be needed. Admission to the PRTF and provision of treatment must begin before the resident reaches the age of 21. Individuals who reach age 21 at the time they are receiving services are eligible to continue receiving services until they no longer require services or until they reach age 22, whichever occurs first. Eligibility for CABHH include: Patients must be pre-screened by DCT Central-Preadmission staff and have a referral from a medical or mental health professional indicating a need for hospitalization. Meet the requirements for hospitalization and does not offer any kind of non-acute care residential treatment services. Eligibility for MHM services will require completion of MnCHOICES assessment. Eligible providers must have demonstrated experience serving children and young adults with serious emotional disturbance/ complex mental illness and trauma in residential and/or inpatient settings. Providers must act in a culturally competent manner, and to the extent possible, incorporate relevant cultural or ethnic practices of clients and their families into transition services. The successful Responder must detail how all statutory requirements regarding staffing qualifications for mobile transition team roles will be met. All providers should be licensed (if applicable) or otherwise certified in their area of expertise by the appropriate Minnesota licensing board. Mobile transition teams must also be able to travel to facilities or communities on behalf of the youth to facilitate meetings or care coordination. Teams may assist in the transportation of youth upon discharge or transition to Community or other service. Any requests for transportation assistance must be coordinated in conjunction with safety protocols according to the child’s risk management or treatment plan and be approved by a supervising physician or mental health professional at the facility. Once a candidate for transition services has been identified, it is expected that the transition team coordinate closely with the PRTF/ CABHH/ inpatient hospital, and any other community support (county, school, caregivers, next of kin, etc.) to expedite discharge to aftercare services as timely as possible. Transition services will also be available to children that require an alternative treatment setting due to current placement or admission not meeting needs. Mobile transition teams will furnish monthly reports to DHS with the following: Number of youths currently involved in transition services Expected outcomes of transition team involvement Youth demographics Mental health diagnoses Plan for return to Community Include status of enrollment in MHM services Location/ living arrangement of Community placement Mobile transition teams will collaborate with DHS Office of Medicaid Medical Director to develop and implement an evaluation plan to track the process and measure outcomes of the services. Mobile transitions teams will conduct follow up with youth/family at least 3-6 months after transition. At least 2-3 documented attempts via phone or email must occur within specified timeframe Mobile transition teams will identify situations where returning to home is not an option due to safety concerns. Teams will identify what can be done in facility to improve situation at home Teams will assist in the implementation of Community-based services to support family/ caregivers for successful integration and permanency in home. Mobile transition teams will facilitate the youth’s transition back to school following discharge from PRTF/ CABHH where appropriate. Teams will ensure coordination among the professionals at the treatment facility, family, and child’s school in the community to ensure successful transition. Teams will provide ongoing consultation with school mental health professionals for support for up to 6 months or more post discharge from PRTF/ CABHH
