AHCCCS Integrated System of Care (ISOC)
Background
In 2001, the Jason K. Settlement Agreement established the Arizona System of Care as a set of values and principles to guide behavioral health service delivery to children in Arizona.
On July 1, 2016, the Arizona Department of Health Services, Division of Behavioral Health moved to AHCCCS to further integrate physical and behavioral health care within the AHCCCS health care delivery system. Since then, AHCCCS has continued to advance the System of Care model to include the adult population and to incorporate an integrated health perspective.
The goal of the Integrated System of Care is to ensure appropriate, adequate, and timely services for all persons across the lifespan, with a primary focus on improving quality of life throughout all system intersections and service interactions that individuals may encounter.
System Oversight Structure
Policies related to SOC
- Integrated System of Care Structure, Values and Principles - AMPM 100
- Table of AHCCCS Covered Services - AMPM 300
- Title XIX XXI Behavioral Health Service Benefit - AMPM 310-B
- Services With Special Circumstances – AMPM 320
- AMPM 320-O Behavioral Health Assessments, Service, and Treatment Planning
- AMPM 320-P Serious Mental Illness Eligibility Determination
- AMPM 320-R Special Assistance for Members with Serious Mental Illness
- AMPM 320-S Behavior Analysis Services
- AMPM 320-U Pre-Petition Screening, Court Ordered Evaluation, and Court Ordered Treatment
- AMPM 320-V Behavioral Health Residential Facilities
- AMPM 320-W Therapeutic Foster Care for Children
- AMPM 320-X Adult Behavioral Health Therapeutic Homes
- Care Coordination Requirements - AMPM 580s
- AMPM 580 Child and Family Team
- AMPM 581 Working with the Birth Through Five Population
- AMPM 582 Support and Rehabilitation Services for Children, Youth, and Young Adults
- AMPM 583 Family Involvement in the Children’s Behavioral Health System
- AMPM 584 Youth Involvement in the Children’s Behavioral Health System
- AMPM 585 The Unique Needs of Children, Youth, and Families Involved with Department of Child Safety (DCS)
- AMPM 586 Children’s Out of Home Services
- AMPM 587 Transition to Adulthood
- Coordination of Care with Other Government Agencies – AMPM 541
- Behavioral Health Services for Children in Department of Child Safety (DCS) Custody and Adopted Children – ACOM 449
Forms related to SOC
- Conditional Release Monthly Monitoring Report
- Arizona State Hospital Admission and Discharge Deliverable Template
- CBHSF Deliverable Template Effective 06/2021
- Children's Behavioral Health Services Fund Invoice Effective 03/2022
- Substance Use Treatment Program Reporting Template
Behavioral Health Clinical Chart Audit
In February 2023, AHCCCS reinitiated the Behavioral Health Clinical Chart Audit process. Based on health plan and stakeholder feedback, multiple enhancements have been made to the audit process. The Behavioral Health (BH) Audit portal was developed and formally released for use on May 18, 2023. The BH Audit portal will be utilized by the managed care organizations (MCOs) to conduct the behavioral health audit. It will allow completion of audits in real time as well as efficient opportunities for data analysis. The BH Audit portal follows the BH Audit Tool and the accompanying Behavioral Health Clinical Chart Audit Instruction Guide.
- BH Audit Tool
Note: The BH Audit tool is a template only and is not meant to be used to conduct the audit process. - Behavioral Health Clinical Chart Audit Instruction Guide
- Behavioral Health Clinical Chart Audit Findings and Summary Report
Child and Family Team Practice
AHCCCS continues to work on improving Child and Family Team (CFT) practice. In partnership with its Managed Care Organizations (MCOs), the AHCCCS ISOC and Workforce Development teams implemented a statewide two day, in-person CFT facilitator training. The new training is intended to build the skills of those staff facilitating CFT meetings and to ensure CFT practice aligns with the 12 Principles. CFT training requirements, as well as supervisor coaching and monitoring requirements for CFT facilitators are outlined in AMPM Policy 580. Supervisors will ensure the competency of their staff and monitor the fidelity of the CFTs being facilitated under their supervision using the CFT Supervision Tool. Supervisors will provide coaching on the nine essential elements of CFT practice as needed but can also have staff re-trained in the CFT Facilitator Training, if needed.
The AHCCCS ISOC team is currently working with the National Wraparound Implementation Center to improve care coordination for children with complex needs. The System of Care team will continue to work on improvements and implementation of the Wraparound model throughout 2024 and 2025.
Resources from National Wraparound:
- National Wraparound Implementation Center Wraparound Process Users Guide 2024
- National Wraparound Implementations Center Monthly Minutes QR Codes
Court Ordered Evaluation and Treatment
On September 4, 2020, the Arizona Supreme Court Committee on Mental Health and the Justice System provided a number of recommendations to improve the justice system for those with mental health care needs.
This included a focus on developing strategies to engage and intervene prior to entry into the justice system. In response to the Committee’s recommendations, AHCCCS created a Court Ordered Evaluation / Court Ordered Treatment (COE/COT) committee, which includes members from the Committee on Mental Health and the Justice System and additional system stakeholders (e.g. members of the Court, district attorney’s, mental health providers, state health plan members and the Office of Individual and Family Affairs) and community members.
This committee’s goal is to develop an effective and standardized statewide training on Court Ordered Evaluation and Treatment by the end of 2023. This training will include individual county processes, resources, and user experience from the peer-member/family perspective. The training will be publicly available and intended for a variety of audiences.
For more information related to COE/COT processes, please visit AHCCCS COE/COT webpage.
Project AWARE - Advancing Wellness and Resiliency in Education
Project AWARE (Advancing Wellness and Resiliency in Education) is a federal initiative funded by Substance Abuse and Mental Health Services Administration (SAMHSA) and the US Department of Health and Human Services. The project aims to expand partnership between education and mental health systems at the state and local levels and to develop a sustainable infrastructure for school-based mental health programs and services. The Arizona Project AWARE team is a partnership between Arizona Department of Education (ADE), AHCCCS, and three Local Education Agencies (LEAs). Project AWARE is focused on ensuring access to behavioral health services for students by establishing and promoting referral pathways and partnerships between Local Education Agencies, parents, and behavioral health community providers.
AHCCCS provides continuous education and behavioral health funding sources that enhance wellness for all Arizona students and communities. The education could be online or in-person depending on the interest of the requesting school or district. Project AWARE supports suicide prevention training as required by the Mitch Warnock Act and more information can be found at Suicide Prevention Training for Schools. This is facilitated through a collaborative partnership of the ADE and AHCCCS working as a team to provide suicide prevention training to school staff and community members. School staff take priority, but everyone is encouraged to use this online form to request suicide prevention training. This training could be online or in person depending on the curriculum.
Current and Future Projects & Goals
- Review of ISOC related policy deliverables
- Oversight of Behavioral Health Clinical Chart Audit Process
- Implementation of Early Childhood Service Intensity Instrument (ECSII) as option for assessment of infants and toddlers (children birth through five)
- Child and Adolescent Level of Care Utilization System (CALOCUS) FAQs
- Serious Emotional Disturbance (SED) Eligibility Determination FAQs
- Serious Mental Illness (SMI) Eligibility Determination FAQs
- Behavioral Health Continuum of Care Annual 2022 Report
- Behavioral Health Continuum of Care Fact Sheet
- Oversight of Mercer and WICHE Contracts for monitoring Arnold v. Sarn Settlement Terms
- Continuing implementation of initiatives related to expanded access to behavioral health services and integrated care
- Behavioral health in schools
- Addition of practice tool for treatment guidelines of intellectual and developmental disability (ID/D) population including specific treatment requirements for Autism Spectrum Disorder (ASD)
- Addition of Adult System of Care tools utilizing evidence-based practices
- Continued monitoring of oversight of the MCOs for members on conditional release under the jurisdiction of the Psychiatric Security Review Board
- Involvement in development of workforce competencies related to the System of Care
- Adolescent Substance Treatment Programs
Learn How to Navigate the Health Care System
Here are more resources to help you access services and take care of your health care needs.
- Office of Individual and Family Affairs
- One-page Empowerment Tools for Members and Families
- Learn more about AHCCCS
- How to Apply for AHCCCS
- AHCCCS Medical Policy Manual of Covered Services
- Upcoming public meetings at AHCCCS
Revised 05/28/2024