TSS Schedule Form for
Prescriber/Family & ISPT Collaboration
All Counties
Please include this form in the Recommendations Section
of the Best Practice Evaluation/Re-evaluation
Member Name:
Today's Date
Prescriber:
Apr 29, 2015
MA Level Evaluator (if applicable):
Child/Family Member(s) Involved in the TSS Discussion:
TSS Service Request (please select one):
Day/Time
Monday
Initial POC
Tuesday
Continued Stay POC
Wednesday
Amended POC
Transfer POC
Thursday
Friday
Saturday
Sunday
7AM
8AM
9AM
10AM
11AM
12PM
1PM
2PM
3PM
4PM
5PM
6PM
7PM
8PM
9PM
Total TSS
Hrs/day
Total TSS Hrs/week
- Please discuss the child & family's goals for recovery, resiliency, and independence & how TSS can be used for the purpose of skill building/transfer to attain these
- Please assure that the family and/or caretaker(s) are able to participate as guided by the Tx plan with the goal of skill transfer for all prescribed TSS.
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Time
Write in Day(s) below on the first line & Activity and Behaviors/Symptoms/Focus of Treatment on the second line.
(please use to document activity and behaviors/symptoms which are the focus of treatment for TSS intervention during each day and time period on page 1 when additional space is needed)
Note: Days & times for the same activity with the same focus may be documented together.
Day(s):
Activity & behaviors/symptoms/
treatment focus:
Day(s):
Activity & behaviors/symptoms/
treatment focus:
Day(s):
Activity & behaviors/symptoms/
treatment focus:
Day(s):
Activity & behaviors/symptoms/
treatment focus:
Day(s):
Activity & behaviors/symptoms/
treatment focus:
Day(s):
Activity & behaviors/symptoms/
treatment focus:
Day(s):
Activity & behaviors/symptoms/
treatment focus:
Day(s):
Activity & behaviors/symptoms/
treatment focus:
Day(s):
Activity & behaviors/symptoms/
treatment focus:
Day(s):
Activity & behaviors/symptoms/
treatment focus:
Day(s):
Activity & behaviors/symptoms/
treatment focus:
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Time
Write in Day(s) below on the first line & Activity and Behaviors/Symptoms/Focus of Treatment on the second line.
(please use to document activity and behaviors/symptoms which are the focus of treatment for TSS intervention during each day and time period on page 1 when additional space is needed)
Note: Days & times for the same activity with the same focus may be documented together.
Day(s):
Activity & behaviors/symptoms/
treatment focus:
Day(s):
Activity & behaviors/symptoms/
treatment focus:
Day(s):
Activity & behaviors/symptoms/
treatment focus:
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Instructions for Completing the TSS Schedule Form
for Prescriber/Family and ISPT Collaboration
All Counties
If TSS is being prescribed for a member the TSS Schedule Form must be utilized by the prescriber as part of the recommendation
section of the Best Practice (BP) evaluation/re-evaluation and submitted to the provider for review/discussion at the ISPT meeting
and to Community Care as an attachment to the BP evaluation/re-evaluation with the BHRS packet. If the TSS prescription changes
after the ISPT, prescriber sign-off on the prescriber collaboration form is also required after review of the ISPT summary, which
includes the Final TSS Schedule Form.
Please refer to the “Sample TSS Schedule Form” for further illustration of these directions.
1.You may complete the TSS Schedule Form by hand or on the computer. If hand writing, please write legibly.
2.Complete the identifying information at the top of the form. If a MA level evaluator is assisting a prescriber or completing the
evaluation with prescriber sign-off only, please include the names of both persons in the appropriate locations.
3.Please indicate if this request for TSS Services is being submitted with an Initial Plan of Care (POC), Continued Stay POC,
Amended POC or Transfer POC.
4.Determine the domain and number of TSS hours needed/day and per week with the child and parent after taking the
following into consideration:
a.The level of BHRS Medical Necessity that the child meets
b.The results from the Functional Behavioral Assessment (FBA)
c.The child/family's recovery/resiliency/independency goals
d.The child and family's weekly schedule and availability to participate in treatment
e.The child's developmental level and capacity to participate in treatment
f.The family's ability/motivation to be involved in treatment and transfer/implement skills
g.The day and time that would be most useful for teaching and transfer of skills to the child/family/caregiver
h.Consideration that the child and/or family/caregiver(s) be available and a participant during all provided TSS
services.
5.Record the prescribed hour(s) and associated days on the TSS Schedule Form by specifying the activity during each time
period for which TSS is prescribed and a brief description of the behaviors/symptoms which are a focus of treatment for
TSS intervention during the specific time period. The
6.TSS Schedule Form should highlight the primary areas of need for skill development/transfer, which will assist in the
development of a strengths based treatment plan. If additional space is needed please use backside of the TSS Schedule
Form. Please see the Sample TSS Schedule Form for further illustration.
7.Record the prescribed TSS hours/day and hours/week in the space provided at the bottom
of the TSS Schedule Form. Please Note: This must match the number of hours prescribed in the recommendation section
of the BP evaluation or re-evaluation.
8.After the evaluation the prescriber is required to submit the TSS Schedule Form to the provider for further discussion/input at
the ISPT meeting and to Community Care as an attachment to the BP evaluation or re-evaluation with the BHRS packet.
9.The ISPT team will further discuss the hours identified on the TSS Schedule Form and make any suggestions for change as
discussed and agreed upon by the ISPT team. The ISPT facilitator will record any recommended changes via the Final TSS
Schedule Form, which is part of the ISPT Summary.
10.In the event that the ISPT recommends a change in TSS hours (increase or decrease in number of hours/week, and/or a
change in the activity/domain in which TSS will be implemented), the prescriber must complete the prescriber
collaboration form, which is attached to the ISPT summary. As per the prescriber collaboration form, the prescriber will
select one of three options to finalize the TSS prescription (and/or any other BHRS changes recommended by the ISPT):
a.Same as reported on the psychiatric/psychological evaluation
b.In Full Agreement with the recommendations of the ISPT (as listed on the final TSS Schedule Form)
c.Revised after consideration of the information presented by the ISPT. In this instance the prescriber documents the
final prescription on the collaboration form and reflects this change on the final TSS Schedule Form.
Please note that the prescriber collaboration form does not need to be signed by the prescriber if the prescription for BHRS
remains the same as the prescriber initially recommended in the Best Practice Evaluation/Re-evaluation.
11.The TSS Schedule Form with the final prescription must be submitted with the BHRS packet to Community Care as part of
the BHRS Packet.
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Community Care Expectations for All Prescribers of BHR Services
A prescriber should know the entire continuum of Behavioral Health care available to the child and family and prescribe the most appropriate and
least restrictive/intrusive level of care to meet the child and family's needs. Available services may differ depending on the area in which the
family resides, but could potentially include: Case Management, Crisis Services, Outpatient Treatment, Partial Hospitalization, Family-Based
Mental Health (FBMH), Behavioral Health Rehabilitation Services (BHRS) including Brief Treatment, Multisystemic Therapy (MST), Family
Functional Therapy (FFT), Intensive In-Home Services, Family Focused Solutions Based Therapy, Individual Residential Treatment (IRT), Therapeutic
Foster Care (TFC), Community Rehabilitation Residential Host Home (CRR), Residential Treatment Facility (RTF), and Inpatient Treatment.
The following guidelines are recommended before prescribing TSS or any other BHR Services:
•All TSS services should be recommended based on the individual needs of the child/family and/or caregivers, and can therefore be
recommended at any time.
•Consider recommending professional services (MT and/or BSC) in the natural environment to further assess the child/family strengths,
needs, availability, commitment to treatment and recovery related goals prior to starting TSS services. If professional services are being
considered prior to the use of TSS, there are several ways to add TSS at any time during the current authorization period:
oFor Traditional BHRS requests (a standard 4 month/18 week authorization):
§The prescriber may recommend professional services (MT and/or BSC) to begin immediately, and TSS to begin a few
weeks later during the same authorization period. This will give the MT or BSC an opportunity to assess the child/
family's strengths, needs and availability in the community, complete a FBA and/or develop a comprehensive
treatment plan for the TSS to follow.
§The prescriber may prescribe professional services to begin treatment and add TSS at any time during the authorization
period using the prescriber collaboration form. In this instance the provider will reconvene an ISPT and determine
the need, treatment goals and family/caregiver availability for TSS after an assessment has been completed in the
community by the MT or BSC.
oFor Extended BHRS requests (an authorization for up to 12 month for children on the Autism Spectrum):
§The prescriber may recommend professional services (typically BSC) to begin immediately, and TSS to begin a few weeks
later during the same authorization period. This will give the BSC an opportunity to assess the child/family's
strengths, needs and availability in the community, complete a FBA and/or develop a comprehensive treatment plan
for the TSS to follow.
§The prescriber may prescribe only professional services to begin treatment and add TSS via a Best Practice (BP) Reevaluation once the need, treatment goals and family/caregiver availability has been assessed by the BSC.
oFor Brief Treatment:
§A BP evaluation may be used to recommend Brief Treatment rather than an “assessment by a Master's level clinician”.
This will allow for traditional BHRS to be prescribed using the prescriber collaboration form at any time during the
Brief Treatment authorization period. In this instance the provider will reconvene an ISPT and determine the need,
treatment goals and family/caregiver availability for TSS after an assessment has been completed in the community
by the MT or BSC.
§If a BP evaluation was not completed to begin a Brief Treatment episode, a prescriber can conduct a BP evaluation at any
time during the Brief Treatment episode to reassess the treatment needs and recommend traditional BHRS.
•Review the results of a Functional Behavioral Analysis (FBA) that has been conducted by the MT, BSC, other behavioral health service
provider, or School and prescribe only the amount of TSS services that are necessary to move the child/family/caregiver(s) to their
greatest level of independence in the shortest amount of time.
•Every TSS hour prescribed and authorized must be delivered. Therefore, a prescriber must be knowledgeable about the availability of TSS
resources in the child/family's area. In the event that a BHRS prescription cannot be filled in its entirety, the prescriber is responsible for
participation in interim service planning with the ISPT to consider alternatives, which may include other behavioral health services and/
or supports available via another service system, including natural and community supports, until the prescribed services are available
or deemed no longer necessary.
•Assure that each TSS unit prescribed is being used for clinical skills building, practice and/or transfer of skills to the member, family and/or
caregivers.
•Assure that the amount of services and the environment(s) in which TSS is prescribed and delivered is consistent with symptom priority and
severity.
•Assure that the goal of each TSS hour prescribed is to assist the child/family/caregiver(s) in attaining a level of recovery, resilience and
independence, as defined by the child/family, in their natural environment.
•Review the actual hours of all BHR services delivered at each continued stay review, compare this with the progress the child/family/
caregivers have made and prescribe only the services that are required to move the family to the level of independence they defined as
their overall goals.
•Assure that the child/family/caregivers have time to practice the newly acquired/transferred skills in their natural environment without 1:1
behavioral health coaching so that coaching will be more effective at problem solving and fine tuning their skills as well as enhance the
child/family/caregiver's level of independence in using their newly acquired skills.
•Educate the child/family/caregivers about the purpose of each BHR service prescribed, i.e., these services are part of a behavioral health
treatment plan with the primary goals of skill building, skill transfer and becoming as resilient and independent as possible, while
recognizing that this will look different for different people.
•Educate the child and family about appropriate and inappropriate uses of TSS and BHRS, and/or any other behavioral health service
prescribed/recommended.
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Glossary of Terms
BP evaluation/re-evaluation - Best Practice Evaluation/Re-evaluation 3rd edition; also known as the Life Domain
Evaluation/Re-evaluation in some contracts.
Child - an individual under the age of 21 who is eligible for and prescribed/authorized to receive BHR Services.
Family - the individual(s) with whom the child resides.
Caregiver(s) - an adult who is assuming primary responsibility for the child including, but not limited to, general
child care, safety, activities of daily living, and behavioral control of the child. A caregiver may include a parent,
guardian, relative, teacher, babysitter, or other adult who is assuming the listed responsibilities.
BSC (Behavior Specialist Consultant) - a professional behavioral consultant to the treatment team with expertise
in behavioral management techniques utilizing an Applied Behavioral Assessment (ABA) approach. The BSC is
responsible for conducting a Functional Behavioral Analysis (FBA) to design and direct the implementation of a
behavior modification intervention plan for the child in which the family/caregiver's ultimately carry out. The BSC
provides expertise in behavioral management protocols that the MT and TSS do not have the proficiency to
provide.
ISPT - The Interagency Service Planning Team consists of the following participants; the child (as appropriate); a
responsible family member/guardian; a representative of the county MH/MR program; the prescribing psychologist
or psychiatrist; a representative of the child's school district (school participation is required if services are to occur
in the school), the county children and youth agency or juvenile probation office (if involved with the child/
family), other agencies that are providing services to the child, extended family members and/or other natural
supports identified by the child/parent(s), and the child's Care Manager from the Behavioral Health Managed Care
Organization. The goals of the ISPT meeting are to create a context for restoring hope to the child and family and
to promote constructive, collaborative treatment planning to assist the child and family develop utilize skills thus
leading to their greatest level of independence.
MT (Mobile Therapist) - is a professional Master's level therapist responsible for providing face to face, child
centered, family focused, individualized and family psychotherapy, and behavioral management (only if the
clinician is proficient in ABA techniques), utilizing a strengths based approach, in a setting other than a therapist or
provider's office. The ultimate goal of MT is to improve or stabilize certain behavioral health symptoms exhibited
by children in the domains in which they are occurring; however, MT is not intended to assist children and their
families in dealing with the normal and expected behaviors related to the child's stage of growth and development.
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