Adult Rehabilitative Mental Health Services (ARMHS) are a set of services that were developed to bring restorative, recovery-oriented interventions directly to individuals who have the capacity to benefit from them, whether in their homes or elsewhere in the community. This means that skills that have been lost or diminished due to the symptoms of mental illness can be acquired, practiced, and enhanced whenever and wherever they are needed.
In the past, rehabilitative mental health services were provided by social service agencies and were not widely considered medical services. Over time, professionals in the mental health community became aware of their effectiveness and embraced services that emphasized recovery and the restoration of skills that were impaired or lost due to mental illness. As awareness in the medical community grew, these special services, or components of them, were seen to be both more humane and more cost-effective than institutionalization or hospitalization.
ARMHS includes four components: basic living and social skills, community intervention, medication education, and transitioning to community living.
Basic living and social skills
People need basic living skills and social skills in order to be independent. This component teaches many of these skills and supports individuals as they practice them. Examples include:
Communicating opinions, thoughts and feelings, or key information with others
• Feeling confident in different social roles and settings
• Communicating about, or when in a stressful situation
• Discovering and using community resources to get needs met
• Getting outside help to deal with a difficult situation
• Preventing relapse
• Budgeting and shopping
• Developing a healthy lifestyle
• Learning to cook and eat a healthy diet
• Learning to get around the community
• Monitoring use and effectiveness of medications
• Managing the symptoms of mental illness
• Managing a household
• Finding and retaining a job
• Planning for employment
• Pursuing education
• Re-entering community living after treatment
Most of these skills are developed one-on-one, but some are taught in a group setting, provided that group learning is a benefit for each person in the group, and is specified in her or his treatment plan. (See “Group modality” later in this section.) Each person’s treatment plan specifies the skills that areneeded, how they will be acquired and/or generalized to other similar situations, and in which mode (individual or group) they are to be provided. The plan must make it clear that the intervention is medically necessary.
Community intervention means a series of strategies aimed at reducing barriers to integration in the community, independent living, or securing community living when symptoms of the mental illness have become unmanageable. These strategies minimize the risk of a loss of community living which could result in the loss of a job, eviction, hospitalization, etc.
Services would involve the ARMHS staff person, either with or without the individual present, to work with relatives, guardians, friends, employer, landlord, treatment provider(s), or other significant people in an effort to resolve a difficult situation. The identified resource person would be asked to make some change that would promote or stabilize the person’s independent functioning.
A community intervention
• Must be aimed exclusively at the person’s treatment
• Must be provided on an individual basis-not in a group
• May be conducted in person, or by telephone
• Can be conducted without the individual being present if they cannot be present, or if the strategy could result in a more effective outcome without their presence
Community intervention services are not
• Routine communication among members of a treatment team, a routine staffing, or a care conference
• Telephone contacts that do not conform to the definition of this service or that are not properly documented
• Clinical supervision or routine service coordination activities with other professionals
• Developing a treatment plan
Medication education teaches individuals about mental illness and its symptoms. It also teaches people about the role of prescription medication and its effects, including side effects. Families and/or significant others may participate in medication education along with the client. Only a registered nurse, pharmacist, physician’s assistant, or physician may provide this training. Medication education can be provided either one on one or in a group within a preferred community, home, or office setting.
Transitioning to community living
Transitioning to community living services are provided to an individual who will be leaving a sub-acute level of care service, such as Assertive Community Treatment (ACT), a skilled nursing facility, an Intensive Residential Treatment Services (IRTS) program, or an acute care service such as a regional treatment center, or an inpatient hospital setting.
These services provide a way for a rehabilitation services provider and the sub-acute or acute care provider to work with the person in a mutual manner. By working together, discharge planning can promote successful entry or re-entry into community living.
While closely tied, transitioning services do not duplicate discharge planning services expected of the sub-acute or acute care provider, nor are they provided concurrently or in conjunction with other ARMHS services. An individual may receive these services only when a facility cannot provide them or is not responsible for providing them.
ARMHS services can be the only mental health services that an individual may require, or as a compliment to other services a person may have. ARMHS services may be delivered by multiple ARMHS providers as deemed beneficial by the individual. To assure for service coordination, it is helpful that providers ask potential ARMHS participants what other services they have received or are currently receiving as a part of the admissions process.
Some participants may also require additional services, whether concurrent with or independent of ARMHS. Such as, an intensive residential setting or a brief hospital stay. Coordination of care is imperative to assure continuity and consistency of care and treatment. ARMHS providers must be aware of limitations or additional requirements during concurrent or independent episodes of care among multiple providers. (Link rehab overview -authorization)
Many activities fall outside the scope of ARMHS services. These activities are generally paid as “other covered services,” or else they do not meet the level of medical necessity requirements or are not reimbursable as a health care service. Minnesota Statutes 256B.0623, subd.13, provides the following examples of services that cannot be billed under ARMHS:
• Transporting recipients
• Services provided and billed by providers who are not enrolled or certified to provide ARMHS
• ARMHS performed by volunteers
• Tasks the provider performs for the recipient, such as housekeeping, laundering, grocery shopping, moving the recipient’s household (sometimes called “do-for” services or activities)
• Time spent on-call and not delivering services
• An ARMHS service that is not medically necessary or is not documented as medically necessary
• Social or recreational activities that are not rehabilitative
• Case management services
• Outreach services to potential recipients
• ARMHS services that are provided to a recipient during a hospital, IMD, or residential treatment facility admission
• Room and board services
• Vocational services
A person who is eligible to receive ARMHS:
• Is age 18 or older
• Has received a recent diagnostic assessment by a qualified mental health professional that indicates ARMHS services are medically necessary;
• Has substantial disability and functional impairment in three or more areas, thus markedly reducing self-sufficiency; and
• Has the cognitive capacity to engage in and benefit from rehabilitative services techniques and methods.
Comprehensive diagnostic and functional assessments are required to determine eligibility, medical necessity, and appropriateness of rehabilitation services. It is also important to remember that the goal of this service is to regain or restore lost capabilities associated with the symptoms of the diagnosed mental disorder.
For this service, the initial diagnostic assessment must be:
(a) No more than 180 days old, beginning on the admission date of the current episode of care; or
(b) Must be conducted within 30 days from the admission date; or
(c) Be completed within 5 days of the second meeting following the date of admission.
To establish medical necessity for ARMHS, the functional assessment must do two things:
1) Identify the symptom(s) associated with the diagnosis; and
2) Clearly describe how the mental illness is affecting functioning within a domain.
A good functional assessment makes clear the links among functioning, the mental illness, and the environment
The functional assessment must be completed within 30 days of the start date or admission date, and must be reviewed and updated at least once every 6 months. However, the narrative portion should be updated more often because the person’s abilities and functioning may change as a result of services received.
Individual ARMHS services are usually provided in a person’s home, but they may be provided at the home of a relative or significant other. They may also be provided at a job site, psychosocial clubhouse, drop-in center, classroom, library, or at some other location in the person’s community. Confidentiality is especially important in settings outside the home.
However, ARMHS services can not be provided in a regional treatment center, nursing facility, or acute care hospital unless a person is making the transition to community living in the immediate future and a discharge date has been determined.
Group modality: As distinct from individual work, a group can help individuals by allowing for role-plays, modeling, and practicing skills with peers. Groups afford a safe place to practice new skills before applying them within their life and community. In order for a person to participate in an ARMHS group, the clinical supervisor must approve the use of this modality and document how a group learning environment is medically necessity. In doing so, the clinical supervisor approves the group over individual modality because the structure of a group supports the person’s ability to learn, practice, and generalize targeted skills more effectively.
Each participant in the group has a rehabilitation goal and objective based on his or her service plan. The goal is linked to the group experience. In each session, a rehabilitative intervention is presented to improve a skill. Once learned, the skill is expected to be generalized throughout the participant’s life. The intervention is described in each participant’s progress note along with his or her response to the intervention and plans for the next session.
To account for the different ways adults learn, rehabilitation-oriented groups use visual, auditory, and kinetic styles.
ARMHS groups follow this typical pattern:
Say: Instructor explains the skill set and how it is used in different roles or situations.
Demonstrate: Instructor demonstrates how the skill is used.
Practice: Members practice using the skill with the instructor.
Demonstrate: Instructor repeats the demonstration.
Demonstrate: Members demonstrate the skill with an instructor or peer.
Score: Members evaluate each other’s use of the skill.
Practice: Members practice with each other.
Integration: Before the next group session, members determine how they can use the skill in natural settings.
Summary: Instructor recaps (a) what was learned during the session, (b) how each member will practice or make use of the skill, and (c) the plan for the next session.
Here are some strategies that can make ARMHS groups more effective:
• Arrive early to assure a welcoming environment.
• Come prepared to conduct a group learning experience. Set up the room in advance; have handouts, pens, or other materials ready.
• Connect group members to one another by asking each member’s purpose in participating:
• What goal(s) are you working on?
• How can this group help you meet your goal(s)?
• Make sure that role-plays clearly relate to members’ goals and life situations.
• Ask participants: Who can you practice this skill with today or tomorrow, and where? Ask them to write down the answers in a to-do list.
• At the beginning of the next session, ask each member to recount her or his practice, and to say whether it went well or not so well.
• Talk with ARMHS staff about how engaged the members are and how they are progressing. If progress is lacking, consult with the staff about ways to reinforce the use of new skills in an individual session.