Box 1: Memorandum of Agreement between ABC Agency and XYZ Agency This agreement is made by and between ABC agency and XYZ agency. The purpose of this agreement is to increase the accessibility of mental health services for persons who have limited access to services by establishing an outpatient mental health service via teletherapy, facilitate the referral and delivery of outpatient mental health services, coordinate the services, and define the responsibility of ABC agency and XYZ agency for shared clients. The provision of treatment and services in this agreement is conditioned on the receipt of authorization for preauthorization required by third-party payers. Mental Health Clinic Services ABC agrees to provide mental health services to shared clients, including but not limited to the following: ● Individual and/or group psychotherapy. ● Intake evaluations and diagnostic assessments. ● Development and monitoring of the individual treatment plan (ITP). ● Referral to other services/professionals as deemed medically prudent by the psychiatrist and treatment team, including targeted case management, psychiatric rehabilitation, residential rehabilitation, and supported employment. ● Collaboration with members of the service team. ● Collaboration with other partners, including XYZ agency and continued psychiatric services and medication management services from XYZ agency. ● Emergency and crisis intervention. ● Clients may choose teletherapy services through ABC agency and continue their psychiatric services and medication management services from XYZ agency. ● ABC agency agrees to provide teletherapy services to eligible clients weekly for psychotherapy. With the new client, the therapist will schedule an intake interview and make appropriate referrals to XYZ agency for psychiatric evaluations and medication management. If XYZ agency receives a new client referral, the psychiatrist will refer the client to ABC agency for teletherapy services. ● ABC agency shall accept and serve insurance-eligible clients who are not presently covered but have current proof of eligibility. ● ABC agency agrees to make available to XYZ agency, and other partners in the provision of services, the client information necessary for proper coordination of services in accordance with HIPAA standards. In instances when XYZ agency continues to provide medication management, XYZ agency will also send similar information to ABC agency for proper coordination of services. ● ABC agency agrees that at least one therapist will complete training and certification in telemental health practice and act as a consultant if the need arises. XYZ agency agrees to provide mental health services to shared clients, including but not limited to the following: ● Psychiatric evaluations and medication management. ● Lab requisitions required for medication management. ● Accessibility and assistance to clients using videoconferencing equipment. ● Collaboration with members of the service team. ● Collaboration with other partners (agencies), inpatient psychiatric facilities, and other community agencies. ● Management of emergencies and crisis interventions. ● ABC agency will collaborate with XYZ agency to develop a coordinated plan of safety. In an emergency, a client will be assessed by an on-site XYZ agency provider. If the provider determines that the client is in need of acute psychiatric crisis services, due to safety, medical, or time-constraint issues, the client will be provided services in accordance with local standard operating procedures. ● Either the client or therapist may require the presence of a medical/psychiatric technician during the telemental health sessions depending on the client’s needs. Based on the providers’ current understanding of the patient and the telemedicine consultation process, the selection of an appropriate attendant (physician, therapist, medical/psychiatric technician, or other support staff), if required, will be mutually agreed on before the start of the telemental health session. ● For telemental health sessions where the client or provider has not required the presence of an attendant to be with the client during the session, the following conditions must be met: ○ An attendant who can respond immediately to assist client will be available at XYZ agency. ○ An alternative communication medium (computer, phone, pager) must be available to notify the attendant at (agency). ○ Should an attendant be called, the session may continue, or the client or therapist may elect to end the telemental health session and refer the patient for an in-person evaluation at XYZ agency or a local emergency room if necessary. This referral may be either voluntary or involuntary in accordance with local laws and standard operating procedures.
EliteLearning.com/Social-Work
Book Code: SWFL1825
Page 125
Powered by FlippingBook