Rule-making Standards and Procedures



STATEMENT OF BASIS AND PURPOSE

Senate Bill 13-266 was signed by the Governor, on May 16, 2013, authorizing a statewide behavioral health crisis response system. A mental health or substance abuse crisis can happen at any time and often individuals experiencing a crisis do not have access to the necessary mental health interventions in their community. Due to limited behavioral health crisis response services, individuals are often transported by first responders to emergency rooms or jails, when local interventions would have been a more appropriate, safer, more specialized, and more cost effective. The proposed rules will create service standards for the coordinated statewide crisis response system which provides intervention and stabilization for any individual in Colorado experiencing a mental health or substance abuse crisis.

Pursuant to 27-60-103, C.R.S., these proposed rules establish service standards for a comprehensive, coordinated statewide system that integrates telephone crisis services, walk-in crisis services and crisis stabilization units, mobile crisis services, and respite services. The proposed rules are based on the principles of cultural competence, strong community partnerships, the use of peer supports, the use of evidence based practices, building on existing foundations with an eye towards innovation, utilization of an integrated system of care, and outreach to students through school-based clinics.

The goal of the behavioral health crisis response system is to decrease the use of emergency departments and law enforcement as primary intervening entities for a behavioral health crisis. The behavioral health crisis response system is a community based crisis intervention option that provides services more effectively and efficiently.

An emergency rule-making (which waives the initial Administrative Procedure Act noticing requirements) is necessary:

| |to comply with state/federal law and/or |

| |to preserve public health, safety and welfare |

Explain: N/A

Authority for Rule:

State Board Authority:

26-1-107, C.R.S. (2015) - state board of human services to promulgate rules for programs administered and services provided by the state department; governing program scope and content, requirements, obligations, and rights of clients and recipients. Specifically, 26-1-107(6)(g), C.R.S., provides that the state board shall adopt rules concerning mental health and alcohol and drug abuse programs;

26-1-109, C.R.S. (2015) - state board rules to coordinate with federal programs;

26-1-111, C.R.S. (2015) - state department to promulgate rules for public assistance and welfare activities;

Program Authority:

26-1-105.5(6), C.R.S. (2015) - all rules, regulations, and orders adopted prior to July 1, 1994, in conjunction with powers, duties and functions were transferred to the department of human services;

26-1-108(1.8), C.R.S. (2015) - grants rule-making authority to the state department as established consistent with the powers and the distinction between board rules and executive director rules as provided in statute;

27-60-103(1)(a), C.R.S. (2015) – the state department shall issues a statewide request for proposals to entities with the capacity to create a coordinated and seamless behavioral health crisis response system;

27-60-103(5), C.R.S. (2015) – the state board may promulgate rules to implement the provisions of this section or the services to be supplied pursuant to this section;

27-65-128, C.R.S. (2015) - the department shall make such rules as will consistently enforce the provisions of care and treatment of persons with mental illness;

27-66-102(2), C.R.S. (2015) - the department may adopt reasonable and proper rules to implement community mental health services in this article in accordance with the provisions of section 24-4-103, C.R.S., and consistent with sections 27-90-102 and 27-90-103, C.R.S.;

27-69-101 through 104, C.R.S. (2015) - the department to promulgation of rules and standards for Family Advocacy Programs for Mental Health Juvenile Justice Populations;

|X |Yes | |No |

|X |Yes | |No |

Does the rule incorporate material by reference?

Does this rule repeat language found in statute?

If yes, please explain.

The rule references other sections the crisis response system providers will need to follow within 2 CCR 502-1. Rule references Title 27, Article 65, C.R.S., Care and Treatment of Persons with Mental Illness. Rule references Title 12 in the “licensed mental health professional” definition.

The rule repeats language found in Title 27, Article 60, Subsection 1(a), C.R.S. which includes the principles for which the behavioral health crisis response system is based.

The program has sent this proposed rule-making package to which stakeholders?

Stakeholders who were sent this proposed rule-making package include: Colorado Department of Public Health and Environment (CDPHE); Colorado Department of Health Care Policy and Financing (HCPF); CDHS Colorado Mental Health Institutes; CDHS Division of Child Welfare; Colorado Behavioral Healthcare Council; community mental health centers; mental health clinics; Colorado Designated Managed Service Organizations; Colorado Hospital Association; consumer and family advocacy agencies; designated mental health facilities; substance abuse treatment providers; 27-65 Mental Health Advisory Board for Service Standard and Regulation; Behavioral Health Transformation Council; current Behavioral Health Crisis Response System vendors; representatives for first responders; and, individuals with lived experience.

[Note: Changes to rule text are identified as follows: deletions are shown as “strikethrough”, additions are in “all caps”, and changes made between initial review and final adoption are in brackets.]

Attachments:

Regulatory Analysis

Overview of Proposed Rule

Stakeholder Comment Summary

REGULATORY ANALYSIS

(complete each question; answers may take more than the space provided)

1. List of groups impacted by this rule:

Which groups of persons will benefit, bear the burdens or be adversely impacted by this rule?

Every person in the State of Colorado will benefit from having a coordinated statewide behavioral health crisis response system which provides intervention and stabilization for individuals experiencing a mental health or substance abuse crisis. A behavioral health crisis does not discriminate based on age, race, sex, religion, economic status, level of education, employment, income level or location. The behavioral health crisis response system is designed to provide support to any individual experiencing a crisis, any time in any location across Colorado. Colorado Senate Bill 16-1405, the Long Appropriations Bill, allocates $25,948,915 to various components of the Behavioral Health Crisis Response System. The appropriated moneys allow any individual, regardless of ability to pay, to access services through the Behavioral Health Crisis Response System.

The Behavioral Health Crisis Response System Rules establish service standards across Colorado, including staff credential requirements. Rural areas in Colorado may find it difficult to hire staff with certain credentials to fill required positions. The Office of Behavioral Health believes that every individual in Colorado, in need of support for a behavioral health crisis should receive those services from skilled professionals trained to manage a behavioral health crisis.

2. Describe the qualitative and quantitative impact:

How will this rule-making impact those groups listed above? How many people will be impacted? What are the short-term and long-term consequences of this rule?

The United States Census Bureau estimates, as of July 1, 2015, the population of Colorado being over 5.4 million. According to the Colorado Tourism Office a record 71.3 million people visited Colorado in 2014, with tourism trends expected to continuing to increase. All 5.4 million residents of Colorado and all 71.3 million visitors to Colorado have the potential to be impacted by these rules. All individuals in Colorado may utilize the Behavioral Health Crisis Response System, regardless of their ability to pay.

The short-term consequences of these rules include establishing a standard for services under the Behavioral Health Crisis Response System, setting achievable expectations for crisis service providers, and most importantly providing the best behavioral health crisis services to individuals in Colorado.

The long-term consequences of these rules include establishing a statewide standard of care when responding to a behavioral health crisis, making Colorado a national leader in the management of behavioral health crises and providing another level of support for individuals in Colorado.

3. Fiscal Impact:

For each of the categories listed below explain the distribution of dollars; please identify the costs, revenues, matches or any changes in the distribution of funds even if such change has a total zero effect for any entity that falls within the category. If this rule-making requires one of the categories listed below to devote resources without receiving additional funding, please explain why the rule-making is required and what consultation has occurred with those who will need to devote resources.

State Fiscal Impact (Identify all state agencies with a fiscal impact, including any Colorado Benefits Management System (CBMS) change request costs required to implement this rule change)

Colorado Senate Bill 16-1405, the Long Appropriations Bill, allocates $25,948,915 in General Fund monies to the components of the Behavioral Health Crisis Response System, which include the crisis hotline, walk-in services, mobile crisis services, respite services, and marketing.

County Fiscal Impact

Moneys allocated to the crisis response system from the State’s General Fund and distributed through contracts. Depending on the contracts, county resources may be used, but should be covered by the allocated General Fund moneys.

Federal Fiscal Impact

These rules have no federal fiscal impact.

Other Fiscal Impact (such as providers, local governments, etc.)

No other fiscal impact is expected.

4. Data Description:

List and explain any data, such as studies, federal announcements, or questionnaires, which were relied upon when developing this rule?

Researching and reviewing other state’s behavioral health crisis services was an important part of the rules development process. Behavioral health crisis services in Arizona, Maryland, Minnesota, New Jersey, Oklahoma, Ohio, and Texas were reviewed. Those state’s established models of care significantly impacted how Colorado’s behavioral health crisis response system rules were formatted and established.

5. Alternatives to this Rule-making:

Describe any alternatives that were seriously considered. Are there any less costly or less intrusive ways to accomplish the purpose(s) of this rule? Explain why the program chose this rule-making rather than taking no action or using another alternative.

The initial round of establishing contracts for the crisis response system was completed without the regulatory oversight that rules provide. This initial process created four (4) crisis regions and standards were created specific to those regions. With individuals moving from region to region and service availability being different across regions, the Office of Behavioral Health sees the creation of rules as imperative in having a more coordinated and seamless statewide system.

OVERVIEW OF PROPOSED RULE

Compare and/or contrast the content of the current regulation and the proposed change.

|Section Numbers |Current Regulation |Proposed Change |Stakeholder Comment |

|21.1|Facilities |Add |_ |

|20.3|Designated |Cris| |

| |to Provide |is | |

| |Mental |Stab| |

| |Health |iliz| |

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| | |n | |

| | |Unit| |

| | |s to| |

| | |the | |

| | |list| |

| | |of | |

| | |faci| |

| | |liti| |

| | |es | |

| | |that| |

| | |must| |

| | |be | |

| | |desi| |

| | |gnat| |

| | |ed | |

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| | |prov| |

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| | |ment| |

| | |al | |

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| | |th | |

| | |serv| |

| | |ices| |

| | |. | |

Have these rules been reviewed by the appropriate Sub-PAC Committee?

| |Yes |X |No |

Date presented PAC on June 2, 2016 . Were there any issues raised? ___ Yes X No

If not, why.

This rule-making packet was presented at the Policy Advisory Committee (PAC) meeting on June 2, 2016. There is not a Behavioral Health Sub-PAC Committee, so the review took place at the PAC meeting without a Sub-PAC Committee review. No issues were raised and the rule promulgation process will proceed.

Comments were received from stakeholders on the proposed rules:

|X |Yes | |No |

If “yes” to any of the above questions, summarize and/or attach the feedback received, including requests made by the State Board of Human Services, by specifying the section and including the Department/Office/Division response. Provide proof of agreement or ongoing issues with a letter or public testimony by the stakeholder.

GENERAL COMMENTS

• I see you all took out the Training Requirements and Data Requirements sections, did these get moved somewhere else? 

• The only section I see missing is the Data Requirements section. 

o Response: Due to the range of potential trainings and specific needs of providers working under these rules, making requirements for specific trainings will limit provider’s ability to address their staff’s specific training needs. Staff training will be addressed in provider contracts.

• The Office of Behavioral Health agrees that a requirement specific to data should be in the rule. Section 2.1 will be added, requiring crisis system service providers to follow Section 21.130 in 2 CCR 502-1, outlining data reporting requirements.

• Any opportunity to clearly separate the Walk in services from CSU services should be taken within rule.

o Response: The Office of Behavioral Health feels that Walk-In Crisis Services and Crisis Stabilization Units should remain joined. Crisis Stabilization Units must have the capacity to provide walk-in services in each of their locations. This model represents another level of care for individuals seeking services for a behavioral health crisis. Crisis Stabilization Units with walk-in services will be able to provide that needed intervention on-site.

21.400.1 DEFINITIONS

• It is unclear whether the definition of "crisis stabilization unit" is the same as a "crisis stabilization center" which is a facility type required to be licensed by CDPHE under 6 CCR 1011-1, Chapter 9 (CCs and CCECs) or Chapter 6 (ATUs). If that is the case, CDPHE suggests that the definition include language that mentions that license requirement.

o Response: The Office of Behavioral Health agrees that language needs to be added into the “crisis stabilization unit” definition clarifying that each unit is to be licensed by the Colorado Department of Public Health and Environment (CDPHE). Crisis Stabilization Units are licensed by CDPHE as Community Clinics or Acute Treatment Units, and must also follow the corresponding CDPHE rules governing such facilities.

• Does a “peer specialist” have to be trained in all of the Combined Core Competencies, Peer Specialist/Recovery Coaches and Family Advocates/Family Systems Navigator?

o Response: The Combined Core Competencies training covers peer specialists, recovery coaches, family advocates, and family system navigators. If an individual is going to provide “peer support” they need to meet the requirements of a “peer specialist” and have completed the Combined Core Competencies training, which encompasses all peer support specialties.

• In the supervision definition, I do not agree that weekly individual clinical guidance is necessary if small group supervision (under 5 attendees) is already occurring weekly. Individual supervision should be on an as needed basis if group supervision is already occurring weekly.

o Response: The Office of Behavioral Health agrees that the “supervision” definition may be too restrictive. The Office of Behavioral Health will remove the word “individual” from the definition allowing more flexibility within supervision sessions.

• With the urban definition, there are still cities in Larimer and Weld that we will not be able to provide a mobile response within 1 hour based on travel time alone. Agreeing to this definition as it is written, sets the teams up for failure with an unrealistic standard, or means that we know we will show poor outcomes when responding to these locations.

o Response: The Office of Behavioral Health supports using broader language for crisis response timeliness standards. Mobile crisis timeliness standards will be addressed in contracts to account for regional differences.

21.400.3 TELEPHONE CRISIS SERVICES

• In 21.400.3(D), telephone crisis must "initiate" Mobile Crisis Services when indicated. I disagree with "initiate". Telephone crisis can refer to the contracting agency that provides Mobile Crisis services, but it is up to the contracting agency to respond to the call, screen and assess the situation, and determine if mobile response is the best response. Each contracting agency has its own procedures for initiating a mobile response, and these procedures are based on unique communities and geographic areas. The contracting agency must have the responsibility to initiate a mobile response; the Telephone crisis can recommend and refer.

o Response: As described in Section 27-60-103, C.R.S. the Behavioral Health Crisis Response System is a coordinated and seamless system reflecting a continuum of care with support for transitions between each stage of service. The idea of a seamless coordinated system would allow for an individual in crisis to call the crisis line. If a crisis line clinician determines that a mobile crisis response is warranted, the mobile crisis request should be initiated. If mobile crisis teams are not responding to a request, the reason for not responding needs to be documented.

21.400.5 MOBILE CRISIS SERVICES AND UNITS

• In 21.400.5(E), utilize peer supports in mobile response, in conjunction with skilled professional. I would propose to utilize peer supports or EMTs for mobile response (in conjunction with skilled professional). We operate an integrated care model, and have found significant value in EMTs providing medical screenings for patients experiencing a crisis. A skilled professional paired with an EMT is an incredible team. Adding a 3rd person (a peer) is too much, and over utilizing resources.

o Response: The Office of Behavioral Health agrees that Emergency Medical Technicians (EMT) can be a useful resource for mobile crisis services. The Office of Behavioral Health feels that incorporating a specific professions into rules, may limit the ability of a mobile crisis service provider to pursue innovative approaches in how they handle behavioral health crisis’ in their region. As outlined in Title 27, Article 60, C.R.S. the use peer supports is an important aspect of the behavioral health crisis response system. The Office of Behavioral Health is aware that not every mobile response should be done in conjunction with a peer specialist. This is the reason the rule states that peer supports should only be utilized in a mobile response when clinically appropriate. The mobile response team should be assessing every request for the appropriateness of utilizing a peer support in the response.

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