Program Goals: Mental health skill building provides training and support to enable individuals ages 18 + with significant psychiatric functional limitations to achieve and maintain community stability and independence in the most appropriate, least restrictive environment. Mental Health Skill Building service is a goal directed training to enable individuals to achieve and maintain community stability and independence in the most appropriate, least restrictive environment. The population served can also include developmental disabilities and/or Substance Abuse as a secondary diagnosis.

Mental Health Skill Building Services will be provided through a designated multi-disciplinary team of mental health professionals. Mental Health Skill Building Services is a team treatment approach designed to provide comprehensive, community-based support to persons with persistent mental illness.

A team of professionals whose backgrounds and training include social work, rehabilitation, positive behavior support, substance abuse, and counseling provide mental health supports. Among our services, Phoenix, LLC provides: initial/ongoing assessment and treatment, medication management, therapeutic groups, Job skills training/obtainment and retention, housing assistance, family support and education, substance abuse services, coordination of healthcare services, community involvement, functional skills and appropriate behavior related to the individual’s health and safety; activities of daily living, and use of community resources; assistance with medication management; and monitoring health, nutrition, physical condition, and other supports critical to an individual’s ability to live successfully in the community. The intended outcome of treatment can result in an individual living independently, successfully within the community free of homelessness, involvement in the judicial system, and all other restrictive systems posing difficulties in their daily living, thus leading to a life of productivity, meaning, and value.

The mission of Phoenix, LLC is to promote the well-being of the individuals and families in the community by providing accessible, quality mental health and support for adults, utilizing a service system that emphasizes trust, respect, confidentiality, and compassion.  We are committed to quality mental health care that is provided in a collaborative effort with individuals’ overall health strategies and an array of medical services. We are further committed to the philosophy that we exist for the customer.

Population Served:  The individual must be aged 18 years or older and is best served in the community. Individuals must demonstrate a clinical need for the service arising from a condition due to mental, behavioral, or emotional illness that results in significant functional impairments in major life activities and affects their ability to remain stabilized in the community. The population served can also include developmental disabilities and/or Substance Abuse as a secondary diagnosis. Individuals must meet at least two of the following criteria on a continuing or intermittent basis:

1. Have difficulty in establishing or maintaining normal interpersonal relationships to such a degree that they are at risk of hospitalization, homelessness, or isolation from social supports.
2. Exhibit such inappropriate behavior that repeated interventions by the mental health, social services, or judicial system are necessary.
3. Exhibit difficulty in cognitive ability such that they are unable to recognize personal danger or recognize significantly inappropriate social behavior.
4. Require help in basic living skills, such as maintaining personal hygiene, preparing food and maintaining adequate nutrition, or managing finances to such a degree that health or safety is jeopardized.

NEW CRITERIA EFFECTIVE 1/12/2023

Service Definition Critical Features & Service Components

Mental health skill-building services (MHSS) shall be defined as goal directed training and supports to enable restoration of an individual to the highest level of baseline functioning and achieve and maintain community stability and independence in the most appropriate, least restrictive environment. MHSS services shall provide face to face activities, instruction, interventions, and goal directed trainings that are designed to restore functioning and that are defined in the ISP in order to be reimbursed by Medicaid. MHSS shall include goal directed training in the following areas: (i) functional skills and appropriate behavior related to the individual’s health and safety; instrumental activities of daily living, and use of community resources; (ii) assistance with medication management; and (iii) monitoring health, nutrition, and physical condition with goals towards self-monitoring and self-regulation of all of these activities.

MHSS services include the following components:

• Providing opportunities to enhance recovery plans that include but are not limited to:

• • Daily living activities and trainings on personal care/hygiene to restore and regain functional skills and appropriate behavior related to health and safety; and,
  • Skills training and reinforcement on the use of available community resources, such as public transportation to improve daily living and community integration skills and independent use of community resources, etc.

• Recovery and symptom management activities that include but are not limited to:
  • Condition specific education and training and reinforcement of symptom identification designed to increase he individual’s ability to recognize and respond to symptoms; and
  • Goal directed and individualized stress management and coping skills training to increase the individual’s continued adjustment to management of mental illness; and
  • Training and coaching to facilitate improved communication, problem solving and appropriate coping skills, etc.
• Assistance with medication management.
• Conducting targeted exercises and coaching to restore and individual’s ability to monitor and regulate their health, nutrition, and physical condition that includes but is not limited to:
  • Self-assessment exercises and recovery coaching that builds self-awareness of symptoms and how to identify and monitor symptoms; and
  • Coaching and training on maintaining adherence to recommended medical care such as scheduling and keeping medical appointments, etc.

Service Eligibility Requirements: Admission Criteria Diagnosis, Symptoms, and Functional Impairment

Individuals qualifying for MHSS must demonstrate a clinical necessity for the service arising from a condition due to mental, behavioral, or emotional illness that results in significant functional impairments in major life activities. Individuals aged 21 and over shall meet all of the following criteria in order to be eligible to receive MHSS:

A. The individual shall have one of the following as a primary mental health diagnosis:

1) Schizophrenia or other psychotic disorder as set out in the DSM-5,

2) Major Depressive Disorder;

3) Bipolar I or Bipolar II;

4) Any other serious mental health disorder that a physician has documented specific to the identified individual within the past year that includes all of the following: (i) is a serious mental illness; (ii) results in severe and recurrent disability; (iii) produces functional limitations in the individual’s major life activities that are documented in the individual’s medical record, AND; (iv) the individual requires individualized training in order to achieve or maintain independent living in the community.

B. The individual shall require individualized goal directed training in order to acquire or maintain self-regulation of basic living skills such, as symptom management; adherence to psychiatric and physical health medication treatment plans; appropriate use of social skills and personal support system; skills to manage personal hygiene, food preparation, and the maintenance of personal adequate nutrition; money management; and use of community resources.

C. The individual shall have a prior history of any of the following: (i) psychiatric hospitalization; (ii) community stabilization, 23-hour crisis stabilization or residential crisis stabilization unit services, (iii) ICT or Program of Assertive Community Treatment (PACT) services; (iv) placement in a psychiatric residential treatment facility as a result of decompensation related to the individual’s serious mental illness; or (v) a temporary detention order (TDO) evaluation pursuant to the Code of Virginia §37.2-809(B). This criterion shall be met in order to be initially admitted to services, and not for subsequent authorizations of service. Discharge summaries from prior providers that clearly indicate (i) the type of treatment provided, (ii) the dates of the treatment previously provided, and (iii) the name of treatment provider shall be sufficient to meet this requirement. Family member statements shall not suffice to meet this requirement.

D. The individual shall have had a prescription for antipsychotic, mood stabilizing, or antidepressant medications within the 12 months prior to the Comprehensive Needs Assessment. If a physician or other practitioner who is authorized by his license to prescribe medications indicates that anti-psychotic, mood stabilizing, or antidepressant medications are medically contraindicated for the individual, the provider shall obtain medical records signed by the physician or other licensed prescriber detailing the contraindication. This documentation shall be maintained in the individual’s MHSS record, and the provider shall document and describe how the individual will be able to actively participate in and benefit from services without the assistance of medication. This criterion shall be met upon admission to services, and not for subsequent authorizations of service. Discharge summaries from prior providers that clearly indicate (i) the type of treatment provided, including psychiatric medication history, (ii) the dates of the treatment previously provided, and (iii) the name of treatment provider shall be sufficient to meet this requirement. Family member statements shall not suffice to meet this requirement.

Individuals 18-20 years shall meet all of the above medical necessity criteria listed in paragraphs 1 through 2 (A-D) in order to be eligible to receive MHSS and the following:

E. The individual shall not be in a supervised setting as described in §63.2-905.1 of the Code of Virginia. If the individual is transitioning into an independent living situation, services shall only be authorized for up to six months prior to the date of transition.

Individuals eligible for this service may have a dual diagnosis of either mental illness and developmental disability or mental illness and substance use disorder. If an individual has co-occurring mental health and substance use disorders, integrated treatment for both disorders is allowed within MHSS as long as the treatment for the substance use disorder is intended to positively impact the mental health condition. The impact of the substance use disorder on the mental health condition must be documented in the Comprehensive Needs Assessment, the ISP, and the progress notes.

Discharge Criteria:

Services will be terminated if individuals no longer meet eligibility criteria for services. Clients in need of other services will be referred. Individuals must meet at least one of the following criteria to be discharged:

1. Change in the individual’s residence to a location out of the service area;
2. Death of the individual;
3. Significant sustained goal attainment and is able to function independently without interventions from the judicial or mental health system.
4. Decline or refuse services and request discharge, despite the staff’s best efforts to develop and/or adhere to a treatment plan with the client.

Referrals sources include managed care organizations, community partners, self-referrals, physicians, other behavioral health agencies, Department of Social Services, and court system.