222 Behavioral Health Coaching | HCBS-5300-MANUAL
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Georgia Division of Aging Services |
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Chapter: |
200 |
Effective Date: |
09/20/2021 |
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Section Title: |
Behavioral Health Coaching |
Reviewed or Updated in: |
MT 2022-01 |
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Section Number: |
222 |
Previous Update: |
MT 2022-01 |
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222.1 Summary Statement
This chapter establishes guidelines and requirements to be followed when Area Agencies on Aging (AAAs) provide or contract for the provision of behavioral health coaching services. The primary goal of this policy is to provide maximum flexibility for AAAs to expand services, while continuing to protect the health, safety, and well-being of persons living with a behavioral health diagnosis.
222.2 Scope
These requirements apply to services provided in whole or in part with non-Medicaid federal and specially appropriated state funds managed by AAAs, and any associated matching and local discretionary funds. These requirements may also provide guidance to agencies implementing behavioral health coaching services funded by other sources.
222.3 Target Group and Eligibility
The target group for these services comprises persons who have mental health, substance use or misuse, and/or memory challenges and who may benefit from a person-centered coaching model to maintain or enhance their ability to live in the community successfully.
The AAA may use other allowable, non-federal fund sources for services targeting individuals who do not meet Older Americans Act eligibility criteria.
The AAA may provide behavioral health coaching services to individuals living in public housing authorities or scatter-site housing programs, or who are living independently in the community.
222.4 Access to Services
Behavioral health coaching is intended to serve as an extension of the AAA’s Access to Care model.
The AAA shall receive requests for behavioral health coaching services provided either directly or through their subcontract agencies and maintain and manage waiting lists, as needed. Referrals may come directly to the ADRC or indirectly from behavioral health coaches.
222.5 Core Principles
AAAs will implement behavioral health coaching services according to the following core principles:
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Capacity based: Persons living with behavioral health diagnoses have the capacity for continued growth and autonomy and are the authority on their own needs, have the capacity to know what they need most to achieve well-being, and have abilities, competencies, and resources to help achieve their goals.
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Conflict-free: Program staff remains neutral with no interest in the choices made by consumers nor in the types of services or providers selected by the consumers; and to the extent possible, avoids the appearance of conflicts regarding referrals on behalf of consumers.
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Culturally Competent: Program staff understands and respects the culture of consumers and interacts with them in ways that are culturally and linguistically competent; and appreciates the ways cultural beliefs and values inform the consumer’s acceptance of Service Plan options.
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Individualized: Services should focus on meeting the specific needs and preferences of each individual consumer and/or family through joint development, implementation, and review of the Service Plan.
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Person-Centered: Program staff approaches consumers and families with empathy and an understanding of their life experiences and challenges by searching for and acting upon what is important to that consumer, including their wants, needs, and values.
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Professionally Responsible: Program staff maintains the privacy, confidentiality, health, and safety of consumers by adhering to ethical and legal standards and to program guidelines.
222.6 Service Goals
The goals of providing behavioral health coaching services include:
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Helping clients reconnect with medical providers (including behavioral health, oral health, therapy services, etc.)
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Maximizing public benefits and support services
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Maintaining stable housing
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Helping the individual learn to effectively use a formal and informal support system, and
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Aging in place
222.7 Service Activities
The AAA may provide any of the following activities as components of a robust behavioral health coaching service:
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Assessment – behavioral health coaches will assess individuals in a person-centered manner that may include use of the DON-R, PHQ-9, GAD-7, or any other assessment tool approved by the Division. Coaches must be sensitive to the need to establish trust with individuals to be served through behavioral health coaching; therefore, it may not be possible or desirable to complete an assessment during the initial contact with the individual.
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Service coordination – behavioral health coaches will support individuals in accessing programs that maximize benefits, transportation, housing, caregiver support, social engagement, material aid, and wellness (including chronic disease self-management programs).
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Crisis stabilization - behavioral health coaches may provide an intensive level of hands-on, in-person intervention if the client is in a crisis, such as being in danger of homelessness. This work usually centers around engaging with the client, developing person-centered goals, and helping them navigate access to medical care and personal support services.
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Education – behavioral health coaches may assist individuals in accessing services that help them learn about how to use assistive technology or medical equipment, learn home management skills, or other activities that promote maximum self-sufficiency.
Behavioral Health Coaching includes the following activities that may be included in reimbursement for services:
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Assessment
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Periodic Reassessment
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Service Plan Development and Coordination
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Follow up by telephone, email, or in person with clients and caregivers, when appropriate and necessary, in accordance with program and service requirements
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Coordination with other programs and advocacy on behalf of individuals
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Education with individuals and/or community partners who require assistance in accessing other systems of care
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Education to staff at housing facilities, or education to resident groups or community groups
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Assisting individuals with applying for or accessing public or private benefits programs
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Documentation, data collection, data entry, and programmatic reporting
Travel to and from the homes of applicants/clients for the purpose of assessment or reassessment may not be billed as units. However, travel is a cost of performing this service and should be included in unit cost calculations.
Each AAA must develop protocols for frequency of intervention and levels of support and must monitor compliance with those protocols.
222.8 Staffing
The AAA will provide adequate numbers of staff, qualified by training and experience to implement behavioral health coaching services. The AAA may directly employ staff or contract for the implementation and administration of the program. Qualifications for behavioral health coaches will mirror those for case management (See MAN 5300, CH 210.13#) plus knowledge and experience in behavioral health services.
Each AAA will determine ideal staffing patterns and staff-to-client ratios that reflect the complex nature of the population served.
222.9 Data Collection and Reporting
The AAA and subcontractors will collect, record, and maintain client information in the form and formats specified by the Division. The Division may establish additional reporting requirements and formats, including a required minimum set of data to account for program activities and outcomes.
222.10 Monitoring and Evaluation
The AAA will monitor providers at least annually to assure accountability for the use of program resources and evaluate the effectiveness of the program activities, using criteria and tools specified or approved by the Division, and other discretionary measures. Standards and guidelines established by the Division apply to eligible service components.
The AAA will provide written feedback to providers within thirty (30) days of completing program monitoring and provide technical assistance for continuous improvement in the program.
The Division will evaluate program data periodically and may conduct on-site monitoring evaluations of activities and records.