Medical Necessity Criteria

Residential Treatment Facility for Adults (RTFA) is provided to individuals, age 18 and over who require 24-hour treatment and supervision in a safe therapeutic environment. RTFA is a 24 hour a day/7 day a week facility-based level of care that is recovery focused and should encompass and demonstrate the following recovery principles: self-direction; individualized and person-centered; empowerment; holistic; non-linear; strengths-based; peer support; respect; responsibility and hope.

The RTFA provides individuals with severe and persistent psychiatric disorders therapeutic intervention and specialized programming in a controlled environment with a high degree of supervision and structure. RTFA addresses the identified problems through a wide range of diagnostic and treatment services as well as through training in basic skills such as social skills and activities of daily living needed to transition to community living arrangement. The services are provided in the context of a comprehensive, multidisciplinary and individualized treatment plan that is frequently reviewed and updated based on the individual’s clinical status and response to treatment. This level of care requires at least weekly physician visits. This treatment primarily provides social, psychosocial rehabilitative training and a focus on family or caregiver support. Active family/significant involvement through family therapy is a key element of treatment and is strongly encouraged unless contraindicated. Discharge planning is documented and must begin at admission, including plans for reintegration into the home and community. If discharge to a home/family is not an option, alternative placement must be rapidly identified and there must be regular documentation of active efforts to secure such placement.

Criteria

Admission Criteria

All of the following criteria are necessary for admission:

1. The individual, age 18 and over, has a serious mental illness consistent with a DSM 5 or current DSM diagnosis that causes significant functional and psychosocial challenges that can be expected to improve through treatment, recovery and rehabilitation services.
2. The individual has a physician certification that the individual does not require a higher level of care and cannot be served in a less than 24-hour program
3. The individual is experiencing emotional or behavioral problems in the home, community and/or treatment setting and is not sufficiently stable, either emotionally or behaviorally, to be treated outside of a highly structured 24-hour therapeutic environment.
4. The individual can reasonably be expected to respond favorably to rehabilitative counseling and training in areas such as problem solving, life skills development, medication compliance training and independent or semi independent living as appropriate.
5. The individual has a history of multiple hospitalizations or other treatment episodes at other levels of care and/or a recent inpatient stay with a history of poor treatment adherence or outcome.
6. The individual lacks community/primary supports sufficient to maintain him/her in the community with treatment at a lower level.

Continued Stay Criteria

All of the following criteria are necessary for continuing treatment at this level of care:

1. The individual’s condition continues to meet admission criteria at this level of care.
2. The individual’s treatment does not require a more intensive level of care and no less intensive level of care would be appropriate.
3. Treatment planning is documented and individualized and appropriate to the individual’s changing condition with realistic and specific goals and objectives stated. Treatment planning should include active family or other support systems involvement, unless contraindicated.  The expected benefits from all relevant treatment modalities are documented. 
4. If treatment progress is not evident, then there is documentation of treatment plan adjustments to address such lack of progress. Progress in relation to specific symptoms or impairments is clearly evident and can be described in objective terms, but goals of treatment have not yet been achieved or adjustments in the treatment plan to address lack of progress are evident and there is fair likelihood that the individual will show progress with these changes.
5. Care is rendered in a clinically appropriate manner and focused on individual’s behavioral and functional outcomes.
6. Unless contraindicated: There is a documented active attempt at coordination of care with relevant outpatient providers, community supports, family, guardian, and/or custodian. Additionally, the individual supports or family is actively involved in the treatment as required by the treatment plan, or there are active efforts being made and documented to involve them.
7. When medically necessary, appropriate psychopharmacological intervention has been prescribed and/or evaluated.

The individual is participating in his/her recovery plan which includes specific realistic, objective and measurable recovery goals and plans for appropriate follow-up services. 

Exclusion Criteria

Any of the following criteria is sufficient for exclusion from this level of care:

1. The individual exhibits severe suicidal, homicidal or acute mood symptoms/thought disorder, which requires a more intensive level of care.
2. The individual can be safely maintained and effectively treated at a less intensive level of care.
3. The individual has medical conditions or impairments that would prevent beneficial utilization of services, or is not stabilized on medications.
4. The primary problem is social, legal, economic (i.e. housing, family, conflict, etc.), or one of physical health without a concurrent major psychiatric episode meeting criteria for this level of care, or admission is being used as an alternative to incarceration.

The individual requires a secure facility.

Discharge Criteria

Criteria 1, 2, 3, 4 or 5, in addition to 6 and 7 are sufficient for discharge from this level of care:

1. The individual’s documented treatment plan goals and objectives have been substantially met and/or a safe, continuing care program can be arranged and deployed at an alternate level of care. 
2. The individual no longer meets admission criteria, or meets criteria for a less or more intensive level of care.
3. The individual, family, guardian and/or custodian are competent but non-participatory in treatment or in following the program rules and regulations. There is non-participation of such a degree that treatment at this level of care is rendered ineffective or unsafe, despite multiple, documented attempts to address non-participation issues.
4. The individual is not making progress toward treatment goals despite persistent efforts to engage him/her, and there is no reasonable expectation of progress at this level of care, nor is treatment at this level of care required to maintain the current level of functioning.
5. Consent for treatment is withdrawn, and it is determined that the individual has the capacity to make an informed decision and does not meet criteria for an inpatient level of care. Support systems, which allow the individual to be maintained in a less restrictive treatment environment, have been thoroughly explored and/or secured.
6. The individual can be safely treated at an alternative level of care.

An individualized recovery plan is documented with appropriate, realistic and timely follow-up services particularly peer support services are in place.

Assertive Community Treatment (ACT) is a consumer-centered, recovery-oriented mental health service delivery model that is designed to work closely with individuals by providing comprehensive community-based treatment. It is a self-contained mental health program made up of a multidisciplinary mental health staff, including a peer specialist, who works as a team to provide the majority of treatment, rehabilitation, and support services consumers need to achieve their goals. ACT services are targeted to individuals with severe and persistent mental illnesses that cause symptoms and impairments in basic mental and behavioral processes. Individuals who have had a history of struggling to access or respond to traditional mental health services or difficulty fitting into their community are considered appropriate for this treatment.

ACT services are individually tailored for each consumer through relationship building, individualized assessment and planning, and active involvement with consumers to enable each to find and live in their own residence, to find and maintain work in community jobs, to better manage symptoms, to achieve individual goals, and to maintain optimism and recover. Services, provided in the individual’s primary language, are designed to meet the unique needs of the individual, based on his/her cultural values and norms. Services are predominately delivered offsite in community settings (e.g., a person's home, job site, or homeless shelter). Services include assistance with addressing basic needs (e.g., food, housing, medical care), as well as a comprehensive integrated program of psychosocial rehabilitation services to support improved social, educational, and vocational functioning. In general, these programs assist individuals with such things as understanding their illness; self-care; budgeting; symptom/medication management; and developing or building on skills that would enhance their employability. Services are less structured and more flexible than intensive outpatient program services.

ACT teams provide a vast majority of their clinical interventions in the home or community setting outside of the treatment provider’s office. Individuals living in supported living situations may receive ACT services if the objective is to move the client to more independent living or to more generic community services. ACT also provides mental health services to individuals who are homeless or in imminent risk of becoming homeless. The program has an outreach component geared towards assessment and linkage to appropriate treatment and community services. ACT teams comply with National Program Standards*: serving persons with severe and persistent mental illnesses; multidisciplinary staffing with a least one peer specialist; low staff-to-client ratios and intensive services; staff who work weekday, evening, and weekend/holiday shifts and provide 24-hour on-call services; team organizational and communication structure; client-centered individualized assessment and treatment planning; and up-to-date individually tailored treatment, rehabilitation, and support services.

*These National Standards for ACT Teams, June 2003, were developed with support from the U.S. Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, Community Support Branch, through grant # SM52579-4. The ACT Standards is a companion document to A Manual for ACT Start-Up: Based on the PACT Model of Community Treatment for Persons with Severe and Persistent Mental Illnesses, written with support from the National Alliance for the Mentally III Assertive Community Treatment Technical Assistance Center.

Procedures

Admission Criteria

The following criteria are necessary for admission to this level of care:

1. The individual is age 18 and older and has a severe mental illness diagnosis consistent with DSM 5. Other mental health disorders maybe appropriate in conjunction with symptoms presenting as chronic and persistent and can reasonably be expected to respond to therapeutic intervention. Individuals with the primary diagnosis of substance use disorder, intellectual developmental disorder, or brain injury are not candidates for ACT.

AND

At least two of the following criteria:

2. At least two psychiatric hospitalizations in the past 12 months or lengths of stay totaling over 30 days in the past 12 months that can include admissions to psychiatric emergency services.
3. Intractable (i.e., persistent or very recurrent) severe major symptoms – (e.g., affective, psychotic, suicidal).
4. Co-occurring mental illness and substance use disorders with more than six months duration at the time of contact.
5. High risk or recent history of criminal justice involvement, which may include frequent contact with law enforcement personnel, incarcerations, parole or probation.
6. Literally homeless, imminent risk of being homeless, or residing in unsafe housing. Homeless Individual (literally homeless) is an individual who lives outdoors (street, abandoned or public building, automobile, etc.), or whose primary residence during the night is a supervised public or private facility that provides temporary living accommodations (short-term shelter). Homeless Individual (at imminent risk of being homeless) should meet at least one of the following criteria: doubled-up living arrangement where the individual’s name is not on the lease, living in a condemned building without a place to move, arrears in rent/utility payments with no ability to pay, having received an eviction notice without a place to move, living in temporary or transitional housing that carries time limits, being discharged from a health care or criminal justice institution without a place to live.
7. Residing in an inpatient or supervised community residence, but clinically assessed to be able to live in a more independent living situation if intensive services are provided or requiring a residential or institutional placement if more intensive services are not available.
8. Difficulty effectively utilizing traditional case management or office-based outpatient services or evidence that they require a more assertive and frequent non-office-based services to meet their clinical needs.

Exclusion Criteria

Either of the following criteria is sufficient for exclusion from this level of care:

1. Individual is at imminent (immediate) risk of harm to self or others or has impairment sufficient enough to require a level of service that is more intensive than community-based care.

Continued Stay Criteria

The following criteria are necessary for continuing treatment at this level of care:

1. Severity of illness and resulting impairment continues to require this level of service;
2. Services are focused on reintegration of the individual into the community and improving his/her functioning in order to reduce unnecessary utilization of more intensive treatment alternatives (e.g., residential or inpatient);
3. Active treatment is occurring and continued progress toward goals is anticipated;
4. Treatment planning is individualized and appropriate to the individual’s changing condition and includes the following, as appropriate, to support individuals and promote their ability to pursue/achieve recovery.
   1. Linkage with community agencies, educational presentations;
   2. Assistance and referral with meeting basic needs (e.g., housing, food, medical care);
   3. Psychosocial evaluation and treatment;
   4. Crisis intervention;
   5. Social rehabilitation/habilitation;
   6. Consumer and family support and education (e.g., symptom management);
   7. Coordination and development of natural support systems (e.g., religious organizations, self-help groups, peer support);
   8. Protection and advocacy resources;
   9. Documented expected outcome from relevant treatment modalities;
   10. Coordination of services, including vocational, medical, and educational needs; and
   11. Medication and treatment monitoring.
5.  Individual continues to require services in order to maximize functioning and sustain recovery; or individual's support network (e.g., family, friends, and peers) is insufficient to allow for independent living.

Discharge Criteria

Any one of the following criteria are sufficient for discharge from this level of care;

1. Have successfully reached individually established goals for discharge, and the consumer and program staff mutually agree to the termination of services.
2. Have successfully demonstrated an ability to function in all major role areas (i.e., work, social, self-care) without ongoing assistance from the program, without significant relapse when services are withdrawn, and the consumer requests for the termination of services.
3. Move outside the geographic area of ACT’s responsibility. In such cases, the ACT team shall arrange for transfer of mental health service responsibility to an ACT program or another provider wherever the consumer is moving. The ACT team shall maintain contact with the consumer until this service transfer is implemented.
4. Decline or refuse services and request discharge despite the team’s best efforts to develop an acceptable treatment plan with the consumer.
5. Needs of the individual can be effectively addressed by a lower level of care

The telephone crisis service is a 24-hour a day, 7 day a week “hot-line” service available in each county. The telephone crisis service line receives calls from individuals who perceive themselves or someone else to be in psychological or psychiatric distress. Telephone crisis operators screen incoming calls to determine appropriate approaches, which can include brief counseling and consultation, referral to other services, as well as emergency outreach and coordination. Service is also provided to callers who represent or seek assistance for individuals who are exhibiting an acute problem of disturbed thought, behavior, mood or social relationships.

Severity of Condition Criteria for Placement

This service does not require prior authorization. It is available to anyone who feels the need to call as a result of their experiencing an acute problem of disturbed thought, behavior, mood or social relationship.

Intensity of Service and Continued Stay Criteria

Not applicable to this level of care

Psychosocial Factors

Not applicable

Exclusion Criteria

Anyone is eligible for this service.

Discharge Criteria

Not applicable

The walk-in crisis service is a face-to-face service provided at a licensed facility that welcomes individuals seeking counseling, advice and referral to deal with a crisis. This service includes assessment, information and referral, crisis counseling, crisis resolution, accessing community resources and back-up, including emergency services and psychiatric or medical consultation. The service also provides intake, documentation, evaluation and follow-up. This service is provided by mental health professionals and crisis workers. This service is provided in units of fifteen (15) minutes.

Severity of Condition Criteria for Placement

Walk-in crisis services are available to individuals experiencing a crisis as a result of a severe disturbance of thought or mood, and/or severe concern for their behavior or social relationships.

Intensity of Service and Continued Stay Criteria

Not applicable to this level of care

Psychosocial Factors

Not applicable

Exclusion Criteria

Anyone is eligible for this service.

Discharge Criteria

Not applicable

The mobile crisis service meets the individual in crisis where the individual is located. The service shall be available with prompt response. Service may be individual or team delivered by mental health professionals or crisis workers. Service includes crisis intervention, assessment, counseling, resolutions, referral and follow-up. The service provides back-up and linkages with other services and referrals. Mobile Crisis Services shall be obtained through network providers whenever possible. Prior approval is not required for this service.

Procedures

Severity of Condition Criteria for Participation

This level of care must be requested by the consumer, family member, emergency room staff, law enforcement agencies, social service/mental health agencies or providers.  Individuals are eligible for this level of care if they meet one of the following criteria:

1. Individuals are in an active state of crisis;
2. Suicidal/assaultive/destructive ideas, threats, plans, or attempts as evidenced by degree of intent, lethality of plan, means, hopelessness, or impulsivity; or acute behavioral, cognitive, or affective loss of control that could result in danger to self or others;
3. Individual demonstrates a significant incapacitating or debilitating disturbance in mood/thought that is disruptive to interpersonal, familial, or occupational functioning to the extent that immediate intervention is required; or
4. The intervention must be reasonably expected to improve the individual’s condition or resolve the crisis.

Intensity of Service and Continued Stay Criteria

Not applicable for this level of care.

Psychosocial Factors

Factors such as family dynamics, support system, financial and social need, homelessness, abuse/neglect, current or past trauma, unemployment or other social determinants of health may change the risk assessment and should be considered when making level of care placement decisions.

Exclusion Criteria

Not applicable for this level of care.

Discharge Criteria

The following criterion is sufficient for discharge from this level of care:

1. Individual is released or transferred to appropriate treatment setting based on crisis screening, evaluation, and resolution.

Acute adult inpatient mental health treatment represents the most intensive level of psychiatric care for an individual 18 years and/or older.  Multi-disciplinary assessments and multimodal interventions are provided in a 24-hour secure and protected, medically staffed, and psychiatrically-supervised treatment environment.  Typically, individuals in need of such services display acute psychiatric conditions, which are generally associated with a relatively sudden onset and a short severe course, or a marked exacerbation of symptoms associated with a more persistent, recurring disorder.  They may also pose a significant danger to themselves and/or others or cause destruction of property.

Procedures

Severity of Condition Criteria for Admission

An individual is eligible for this level of care if s/he has been evaluated by a licensed physician, has a psychiatric diagnosis or provisional psychiatric diagnosis and cannot be treated at a less intense level of service because at least one of the following is present:

1. A suicide attempt which is judged by the evaluating psychiatrist to be serious by degree of lethality or intentionality and is accompanied by feelings of hopelessness and helplessness. Impulsive behavior and/or concurrent intoxication increase the need for consideration of this level of care;
2. Current suicidal ideation that places the individual in "real and present danger" (e.g., has a plan and a means for suicide), particularly when accompanying a DSM 5 or current DSM diagnosis:
3. Current assaultive threats or behavior with a clear risk of escalation or future repetition. These behaviors must also result from an DSM 5 or current DSM  disorder for this level of care to be considered;
4. Disordered/bizarre behavior or psychomotor agitation or retardation that interferes with the activities of daily living to such a degree that the individual cannot function at a lower level of care;
5. Disorientation or memory impairment which is due to an DSM 5 or current DSM   disorder and endangers the welfare of the individual;
6. Withdrawal from drugs or alcohol that necessitates a medical inpatient detoxification in conjunction with a co-existing psychiatric diagnosis that indicates potential for disruptive behavior best managed on a secure psychiatric inpatient unit.;* or
7. Inability to maintain adequate nutrition or self-care due to a psychiatric disorder^[1], and family/community support cannot be relied on to provide essential care.

* For individuals with a dual diagnosis of mental illness and substance abuse disorder, placement in a mental health program which is also credentialed to provide substance abuse services may be justified during acute withdrawal.

^[1]This does not result from a primary eating disorder which may be managed at a lower level of care.

Intensity of Service and Continued Stay Criteria

There has been a physical and psychiatric examination completed within 24 hours of admission and at least one of the following criteria is  necessary and present for continued treatment at this level of care:

1. Close and continuous skilled medical observation and supervision to make significant changes in psychotropic medication and/or other treatment modalities;
2. Continuous observation and control of behavior (e.g., isolation, restraining, other suicidal/homicidal precautions) to protect individual, others, and/or property;
3. Close and continuous skilled medical observation due to side effects (e.g., hypotension, arrhythmia) of psychotropic medication; or
4. A comprehensive multi-modal therapy plan which requires close supervision and coordination in a psychiatric setting.
5. There is reasonable expectation based on the person’s current condition and past history, that withdrawal of inpatient treatment will impede improvement or result in rapid decompensation or the re-occurrence of symptoms or behaviors which cannot be managed in a treatment setting of lesser intensity.
6. The person participates in treatment and discharge planning; and
7. Treatment planning and subsequent therapeutic orders reflect appropriate, adequate and timely implementation of all treatment approaches in response to the person’s changing needs

The above must be substantiated by:

1. A description of the degree of progress made in stabilizing the acute symptoms on at least a weekly basis, which must include an evaluation of the effectiveness of the treatment rendered. If the current plan of treatment over a three to seven day period has not resulted in the stabilization of acute symptoms, appropriate revision must be made in the treatment plan, including the possibility of an outside consultation regarding the nature of the appropriate revisions; and
2. An evaluation of psychiatric and/or medical complications that have occurred with a clearly defined plan for therapeutic management of the complications designed to bring about their quick resolution.

Psychosocial Factors

Factors such as family dynamics, support system, financial and social need, homelessness, abuse/neglect, current or past trauma, unemployment or other social determinants of health may change the risk assessment and should be considered when making level of care placement decisions.

Exclusion Criteria

Any of the following criteria are sufficient for exclusion from this level of care:

1. Condition is diagnosed as chronic in nature without acute symptoms and requires transfer to a long-term facility;
2. Symptoms result from a medical condition such as severe hypertension, stroke, infection, which warrants a medical/surgical setting for treatment (some medical conditions such as dementia with behavioral manifestations are not excluded);
3. There are no behavioral symptoms present which require this level of care, and/or the diagnosis is not that of a mental illness

Discharge Criteria

1. The person no longer needs the inpatient level of care because:
   1. The symptoms, functional impairments and/or coexisting medical conditions that necessitated admission or continued stay have diminished in severity and the person's treatment can now be managed at a less intensive level of care; and
   2. The improvement in symptoms, functional capacity and/or medical condition has been stabilized and will not be compromised with treatment being given at a less intensive level of care; and
   3. The person does not pose a significant risk of harm to self or others, or destruction of property; and

OR

1. Inpatient psychiatric treatment is discontinued because:
   1. A diagnostic evaluation and/or a medical treatment has been completed when one of these constitutes the reason for admission; or
   2. The person withdraws from treatment against advice and does not meet criteria for involuntary commitment; or
   3. The person is transferred to another facility/unit for continued inpatient care.

AND

1. There is a viable discharge plan which addresses living arrangements and includes follow-up care

Extended Acute Care treatment provides 24-hour services in a licensed inpatient facility.  Inpatient extended acute treatment represents a less intense psychiatric care than acute inpatient hospitalization but more intensive than Long Term Structured Residential Treatment or partial hospitalization.  Services are directed toward those who present with significant, but not imminent risk, who require less active medical monitoring, have a pattern of difficulty reaching stabilization, and require a secure unit.  Individuals will receive therapeutic interventions and specialized programming in a controlled environment with a high degree of supervision.  Comprehensive services include multi-modal therapies, as well as the use of community resources for planned, purposeful, and therapeutic activities that will encourage the individual’s autonomy.

Procedures

Severity of Condition Criteria for Admission

Individuals are considered a candidate for Adult Inpatient Extended Acute Care criteria if they meet admission criteria “1, 2, 3, 4, 5 and 6”, or “1, 2, 3, 4, 7, 8, 9, and 10”

1. The individual must have a diagnosis of a mental disorder or condition according to the most recent version of the Diagnostic and Statistical Manual of Mental Disorders
2. The individual is likely to respond to professional therapeutic intervention
3. The individual must be 18 years or older
4. The individual must have a referral that resulted from an acute psychiatric inpatient hospitalization and have a psychiatric evaluation that specifically recommends admission to an EAC with medical clearance for admission
5. Documentation that the person poses a significant risk of harm to self or others or is unable to care for themselves
6. Confirmation that the individual’s judgment or functional capacity is so impaired that self-maintenance, occupational, or social functioning is severely threatened
   
   OR
   
   
7. Documentation that the person has a medical condition or illnesses that cannot be managed in a less intensive level of care because the psychiatric and medical conditions so affect each other that there is a significant risk of medical crisis or instability
8. Evidence of clinical documentation that the individual’s judgment or functional capacity is so impaired that self-maintenance, occupational, or social functioning is severely threatened
9. Verification that the person requires treatment that may be medically unsafe or unable to be provided if administered at a less intense level of care
10. Verification that there is an increase in the severity of symptoms such that continuation at a less intense level of care cannot offer an expectation of improvement or the prevention of deterioration, resulting in danger to himself or herself, others, or property

Intensity of Service and Continued Stay Criteria

Each of the following Treatment Continuation Criteria is required throughout the episode of care:

1. The individual continues to meet the treatment initiation criteria each day that services are provided at this level
2. This is the least restrictive level of care available to safely treat the member.
3. There is evidence of improvement or prevention of deterioration of the symptoms of, or impairment in functioning resulting from, the mental disorder or condition that necessitated initiation of treatment, but goals of treatment have not yet been achieved

Exclusion Criteria

Any of the following criteria is sufficient for exclusion in adult extended acute care:

1. The individual exhibits severe suicidal, homicidal, acute mood symptoms/ cognitive disorder or drug/ alcohol concerns which require a more intensive level of care
2. The individual can be safely maintained and effectively treated at a less intensive level of care
3. The individual is seeking services as a way to potentially avoid legal proceedings, incarceration or other legal consequences

Discharge Criteria

All of the following criteria are required for discharge from adult extended acute care (1,2,3,4,and 5) or 6 or 7 or 8:

1. The symptoms, functional impairments, and/or coexisting medical conditions have diminished in severity, and the individual’s treatment can now be managed at a less intensive level of care
2. The improvement in symptoms, functional capacity, and/or medical condition has been achieved and the expectation that these improvements will not be compromised with treatment being given at a less intensive level of care
3. The person no longer  poses a significant risk of harm to self or others, or destruction of property
4. The individual has benefited from extended acute treatment and has developed sufficient coping skills and effective community supports, indicating a high probability of a positive transition to the community
5. The person, with the support of the EACs staff and community after care providers, has developed a viable discharge plan that includes living arrangements and follow-up care to support the person’s transition to the community.

OR

Extended acute inpatient treatment is discontinued because:

6. The person withdraws from treatment against advice and does not meet criteria for involuntary commitment
7. The person exhibits severe disruptive or dangerous behaviors that require immediate attention in a more intense and highly structured or clinical setting
8. The individual is no longer involved in active treatment and the services are predominately domiciliary or custodial and do not include active treatment.

Outpatient therapy usually is an individualized mode of treatment which may occur in a clinic setting or in the offices of a private practitioner and involves the interaction between a therapist and consumer in order to resolve a concrete problem in daily living (problem focused) or symptoms resulting from maladaptive thoughts, feelings, interpersonal disturbances, and/or experiences.  The approach is often educational in nature and directed toward identifying and utilizing available resources.  It is also intended to restore and enhance an individual’s capacity to find solutions.  In addition to the consumer, family members or other caregivers may participate in this level of care.  The problems identified may be recurrent in nature (e.g., those identified by individuals with a persistent recurring mental illness or substance use diagnosis) or may be newly-identified in an individual who has previously experienced a higher level of function and whose symptoms or difficulties are the result of a specific problem which is the focus of this treatment episode.  In the clinic setting, many other services may be utilized in coordination with the individual therapy to complement the effect of the individual therapy.  When the individual is discharged there is the assurance that s/he can return to treatment should additional problems arise.

Procedures

Severity of Condition Criteria for Participation

For each episode of treatment, clinical necessity exists when all of the following conditions are met:

1. There is a clearly identified problem or symptom resulting from a DSM 5 or current DSM diagnosis;
2. The individual is able to actively participate in the treatment with guidance and support.

Intensity of Service and Continued Stay Criteria

All of the following criteria are necessary for continued stay in this level of care:

1. Face-to-face encounter(s);
2. Concrete problem and/or symptom identification and action plan;
3. Assessment for further case identification;
4. Rule out need for more intense levels of service, including substance abuse treatment;
5. Precise documentation of all sessions, assessments, treatment plans, and interventions.

Psychosocial Factors

These factors may change the risk assessment and should be considered when making level of care placement decisions.

Exclusion Criteria

Any of the following criteria are sufficient for exclusion from this level of care:

1. Unable to participate in or benefit from outpatient psychotherapy because of overriding symptoms of major psychiatric illness that may require being treated in a higher level of care
2. Chooses not to participate in this therapeutic process and is not court ordered to do so.

Discharge Criteria

Any of the following criteria are sufficient for discharge from this level of care:

1. Goals of therapy have been achieved;
2. Documented non-participation after multiple attempts at engagement and/or modification of the treatment plan, all carefully documented, with treatment plan; or
3. Movement to more intensive level of care and the same services are available at the more intense level or are unnecessary.

Psychological testing involves the culturally and linguistically competent administration and interpretation of standardized tests to assess an individual’s psychological or cognitive functioning.  Testing is viewed as a potentially helpful second opinion when standardized diagnostic interviewing or therapeutic procedures are unable to sufficiently address the diagnostic or treatment related issues.

Criteria

Admission Criteria

Psychological Testing

Either 1, 2, or 3

1. Testing is needed for a differential diagnosis of a covered mental health condition, which is not clear from a traditional assessment (i.e., clinical interview, and brief rating scales), and diagnostic clarity is needed for effective psychotherapy or psychopharmacotherapy treatment planning.
2. The individual has not responded to standard treatment with no clear explanation of treatment failure, and testing will have a timely effect on the individual treatment plan.
3. When a case can be made for the need of in-depth analysis of case conceptualization, such as in, but not limited to, complex cases.

Neuropsychological Testing

1. Neuropsychological testing should only be requested after a comprehensive psychological/psychiatric evaluation and a recommendation by a licensed psychologist, psychiatrist, or neurologist.
   
   Either 2, 3,  4, or 5
   
   
2. Testing is needed for a differential diagnosis, which is not clear from a traditional assessment (i.e., clinical interview, and brief rating scales), and diagnostic clarity is needed for effective psychotherapy or psychopharmacotherapy treatment planning.
3. The individual has not responded to standard treatment with no clear explanation of treatment failure, and testing will have a timely effect on the individual treatment plan.
4. Mapping out brain dysfunction and identifying pathways for cognitive rehabilitation are critical to the development of a behavioral health treatment plan.
5. When a case can be made for the need of in-depth analysis of case conceptualization, such as in, but not limited to, complex cases.

Exclusion Criteria

1. Testing was administered within the last year, and there is no strong evidence that the patients’ situation or functioning is significantly different.
2. Testing is primarily for educational purposes.
3. Testing is requested within 30 days of active substance use.
4. Testing is primarily to guide the titration of medication.
5. Testing is primarily for legal purposes.
6. Testing is primarily for medical guidance, cognitive rehabilitation, or vocational guidance, as opposed to the admission criteria purposes stated above.
7. Testing request appears more routine than medically necessary (e.g., a standard test battery administered to all new patients).
8. Specialized training by provider is not demonstrated.
9. Interpretation and supervision of neuropsychological testing (excluding the administration of tests) is performed by someone other than a licensed psychologist with a specialty in neuropsychology.
10. Measures proposed have no standardized norms or documented validity.
11. The time requested for a test/test battery falls outside Beacon Health Options established time parameters (and no clinical rationale was provided to justify a longer time period).
12. Extended testing for ADHD has been requested prior to provision of a thorough evaluation, which has included a developmental history of symptoms and administration of rating scales.
13. Symptoms of acute psychosis, confusion, disorientation, etc., interfering with proposed testing validity are present.
14. Administration, scoring and/or reporting of projective testing is performed by someone other than a fully licensed psychologist or other mental health professional whose scope of training and licensure includes such testing.

Continued Stay Criteria

Does not apply.

Discharge Criteria

Does not apply.

* Note the psychologist needs to determine which assessment tools to use based on their assessment of the individual and the questions posed by the consultation request. 

* Any testing that requires more time or materials than has been initially approved will require further utilization management consideration.

* The peer-to-peer review will be conducted by a licensed psychologist.

Family therapy is conducted with the consumer and key family members, as necessary, in order to reduce symptomatology and integrate the individual’s treatment goals into the family unit.  It may also be used to help families cope with the stressors of having a family member with severe mental illness.  Key components of the treatment process include assisting family members with the identification of problems in the relationships within the family as well as identifying and maximizing their strengths and developing problem-solving techniques.

Procedures

Severity of Condition Criteria for Participation

Clinical necessity exists when any the following conditions are met:

1. Individual’s symptoms result from family stressors or dynamics and therefore are expected to be reduced as a result of family therapy;
2. This level of care is necessary in order to integrate the individual’s treatment goals into the family unit;
3. Family/interpersonal relationships are identified as problematic;
4. Family dynamics are seen as a significant precipitant of symptoms and/or stabilization of family dynamics is instrumental to the consumer’s return to the community; or
5. The family is helped to prepare for the return of a family member after an acute level of care and is seen as a significant support for the individual.

Intensity of Service and Continued Stay Criteria

All of the following are necessary to continue to meet clinical necessity:

1. Individual and the family are appropriately participating; and
2. A jointly developed treatment plan, including the identified consumer and family members, is documented to address:
   1. Family strengths;
   2. Family issues to be resolved;
   3. Specific intervention to be used; and
   4. Length of treatment.

Psychosocial Factors

Factors such as family dynamics, support system, financial and social need, homelessness, abuse/neglect, current or past trauma, unemployment or other social determinants of health may change the risk assessment and should be considered when making level of care placement decisions.

Exclusion Criteria

The following criterion is sufficient for exclusion from this level of care:

1. Consumer and/or family chooses not to participate in this intervention.

Discharge Criteria

Any of the following criteria are sufficient for discharge from this level of care:

1. All identified treatment goals have been met; or
2. The individual or family member chooses not to participate with the identified treatment plan which was jointly developed.

Non-acute partial hospitalization is a nonresidential treatment program that may or may not be hospital-based.  The program provides clinical diagnostic and treatment services on a level of intensity less than acute partial hospitalization but more intense than intensive outpatient (IOP) and/or outpatient. These services may include therapeutic milieu, nursing, psychiatric evaluation and medication management, group and individual/family therapy, psychological testing, vocational counseling, rehabilitation recovery counseling, substance abuse assessment and referral and treatment plans. However, these services require less intensive individual intervention for symptom management than in an acute partial hospitalization program.

The environment at this level of treatment is highly structured.  The staff-to-patient ratio will be sufficient to ensure necessary therapeutic services, professional monitoring and protection, and will consist of at least 1 FTE clinical staff member to every 6 patients as per Title 55. Chapter 5210 Partial Hospitalization regulations. Non-acute psychiatric partial hospital treatment may be appropriate when a patient does not require the more restrictive and intensive environment of a 24-hour inpatient setting and/or acute partial hospitalization, but does need a minimum of 12 hours of clinical services per week. 

Non-acute partial hospitalization is used for stabilization and treatment of chronically ill individuals currently in treatment who require more intensive services for some period of time than is provided in outpatient or aftercare programs.  As such, it can be used both as a transitional level of care (i.e., step-down from inpatient) as well as a stand-alone level of care to stabilize a deteriorating condition and avert hospitalization. Beacon Pa certification guidelines (Policy CN.23) indicates precertification up 8 weeks and a continued stay up to 8 weeks.

Treatment efforts need to focus on the individual's response during treatment program hours, as well as the continuity and transfer of treatment gains during the individual's non-program hours in the home/community.  Comprehensive treatment planning is individualized and appropriate to the individual’s changing condition with realistic and specific goals and objectives stated. Treatment planning should include active family or other support systems, social, occupational and interpersonal assessment with involvement when indicated. 

Non-acute psychiatric partial hospital treatment is separate and distinct from acute partial hospitalization program (see CL.13.201) based on the level of intensity of the services as indicated by length of stay, number of days of attendance per week, individual program description and Beacon Pa certification guidelines policy number CN.23. In addition, non-acute psychiatric partial hospital treatment is separate and distinct from psychiatric and social rehabilitation programs or day treatment programs, which focus on maximizing an individual’s level of functioning (e.g., self-sufficiency, communication skills, and social support network). Non-acute psychiatric partial hospitalization and/or day treatment programs are usually less psychiatrically-based, located in a community setting, and focus more on the development or enhancement of an individual’s coping skills necessary for daily social and occupational functioning.

Criteria

Admission Criteria

All of the following criteria are necessary for admission:

1. The individual is age 18 and older and is experiencing an exacerbation of psychiatric symptoms consistent with a DSM 5 or current DSM disorder that requires intensified supportive treatment.
2. There is evidence of the individual’s capacity and support for reliable attendance at the non-acute partial hospitalization program.
3. There is an adequate social support system available to provide the stability necessary for maintenance in the program OR the individual demonstrates the capacity to assume responsibility for his/her own safety outside program hours.
4. The individual’s risk to self, others, or property is not so serious as to require 24-hour medical/nursing supervision and needs could be met at the minimum of 12 hours of clinical services per week. Intensity of an acute partial hospitalization program is not indicated but individual does require structure and supervision for a significant portion of the day and family/community support when away from the non-acute partial hospitalization program.
5. The individual’s condition requires a comprehensive, multi-disciplinary, multi-modal course of treatment, including routine medical observation/supervision to effect significant regulation of medication and/or routine nursing observation and behavioral intervention to maximize functioning and minimize risks to self, others and property.

Psychosocial, Occupational, and Cultural and Language Factors

These factors may change the risk assessment and should be considered when making level of care decisions and reflected in the treatment planning process.

Exclusion Criteria

Any of the following criteria are sufficient for exclusion from this level of care:

1. The individual is an active or potential danger to self or others or sufficient impairment exists that a more intense level of service is required.
2. The individual does not voluntarily consent to admission or treatment and is not involuntarily committed to this level of care.
3. The individual has medical conditions that would prevent beneficial utilization of services and appropriate accommodations cannot be made.
4. The individual can be safely maintained and effectively treated at a less intensive level of care.
5. The primary problem is social, economic (i.e. housing, family conflict, etc.), legal or one of physical health without a concurrent major psychiatric episode meeting criteria for this level of care.
6. The focus of treatment is primarily for peer socialization and group support.

Continued Stay Criteria

All of the following criteria are necessary for continuing treatment at this level of care:

1. The individual’s condition continues to meet admission criteria at this level of care;
2. The individual’s treatment does not require a more intensive level of care, and no less intensive level of care would be appropriate.
3. The individual demonstrates a current or historical inability to sustain/maintain gains without a comprehensive program of treatment services.
4. Progress in relation to specific symptoms or impairments is clearly evident and can be described in objective terms, but goals of treatment have not yet been achieved. If there is lack of progress, appropriate adjustments in the treatment plan are documented.
5. The individual is an active participant in treatment and discharge planning.

Discharge Criteria

The following criteria are sufficient for discharge from this level of care:  

1. There is a discharge plan with follow-up appointments in place prior to discharge.
   
   And any of the following
   
   
2. The individual’s documented treatment plan, goals and objectives have been substantially met.
3. The individual no longer meets the admission criteria or meets criteria for a less or more intensive level of care.
4. Consent for treatment is withdrawn.
5. The individual is not making progress toward treatment goals and there is no reasonable expectation of progress at this level of care despite documented treatment planning changes and a recommendation is made for another level of care.

4.306a - Medication management by a physician applies to situations in which the sole service rendered by a qualified physician is the evaluation of an individual’s need for psychotropic drugs, the provision of a prescription, education of the consumer and ongoing medical monitoring.  For certain individuals, medication management will continue beyond the psychotherapy component of treatment.  For others, medication management will occur in the context of long-term supportive psychotherapy.  Interactive psychotherapy is not rendered by the physician during medication management but may be provided by another clinician.  Intense medication management is sometimes necessary to divert the need to move to a higher level of care, i.e., inpatient hospitalization and may at times be mandated by court order. Medication management is classified in one of two categories:

1. Providing medical supervision and prescribing or evaluating the need for psychotropic drugs to an individual separately from psychotherapy or other visits for care or for one who is in treatment with a non-medical psychotherapist; or
2. Providing medical services, including prescription of psychotropic drugs, to an individual who is not currently in need of psychotherapy.

4.306b - Medication Management by a licensed nurse. This service is provided by a nurse who works under the supervision of a physician in monitoring the drug dosage, side effects and effects of the medication, as well as compliance, weight, nutritional status, and vital signs.  There is also the capability to collect blood and urine samples for drug monitoring and monitoring of the health status. These visits may be weekly or more or less frequent as needed for these functions and will be coordinated with the regular Physician Medication Management visits and with the Primary Care Physician. A certified registered nurse practitioner (CRNP) additionally may diagnose, prescribe and formulate a treatment plan within the scope of licensure in Pennsylvania.

4.306c - Medication Management by a Physician Assistant. This service is provided by a Physician Assistant (PA) working under the supervision of a physician, who can monitor the side effects, drug dosage and effectiveness of medications and actively prescribe within the scope of licensure of Pennsylvania.

4.306d - Medication management groups can provide additional support and improve participation and therapeutic benefit for selected individuals. They should be distinguished from a medication clinic, where individuals are scheduled at the same time but the psychiatrist/nurse meets with them individually for very brief sessions (often used for injections).  The medication management group, in addition to administering prescriptions or injections, must involve: group discussion and education on illness (e.g., what leads to relapse, how to reduce stressors that lead to relapse, problems that may arise when alcohol use is combined with behavioral illness and behavioral medications), mutual support group (e.g., for individuals with severe mental illnesses, the types of resources are available to them for the development of skills around living independently, and maintaining social support network).

Procedures

Severity of Condition Criteria for Participation

Clinical necessity exists under the following conditions:

1. A DSM 5 or current DSM related problem has been identified which is expected to respond to psychotropic medication; and
2. The individual needs to be evaluated for medication use, obtain a prescription, or (for those currently taking psychotropic medication/s) be medically monitored.

Intensity of Service and Continued Stay Criteria

All of the following are necessary to continue to meet clinical necessity:

1. The medication or other medical service is prescribed by a qualified physician, preferably a psychiatrist (non-psychiatrist where psychiatrist is not available, such as rural areas) or, after evaluation by a physician and under supervision of a physician, by a Certified Registered Nurse Practitioner or Physician’s Assistant (physician-extender) acting within the scope of their license;
2. When the physician providing the prescription or medical service is not the consumer’s therapist, the physician collaborates with the psychotherapist and/or treatment team and primary care provider for prescription renewal or adjustment of medications; and
3. The physician meets face-to-face with the consumer on a scheduled basis, determined by the needs of the individual working with the physician:
   1. For individuals with acute needs who are not yet stabilized or are experiencing adverse side effects, physician meets up to once or twice a week, or more often, as dictated by the needs of the individual;
   2. Physician or physician extender meets with the consumer on a regular basis as indicated by clinical need but at a minimum of once every three months with individuals who are stabilized or have long-term needs if the individual’s pharmacological plan is appropriate and s/he is not experiencing complications from the medication(s).

Psychosocial Factors

Factors such as family dynamics, support system, financial and social need, homelessness, abuse/neglect, current or past trauma, unemployment or other social determinants of health may change the risk assessment and should be considered when making level of care decisions.

Exclusion Criteria

The following criterion is sufficient for exclusion from this level of care:

1. Individual chooses not to participate in medication management by refusing medication or by non-adherence to medication directions and there is no court ordered treatment mandating this treatment for this individual.

Discharge Criteria

Any of the following criteria are sufficient for discharge from this level of care:

1. Medication is discontinued as a result of individual’s choice to refuse medication use;
2. Medication management has reached a point of stability in this individual to the extent that it is clinically appropriate and more convenient for the medication management to be transferred to the Primary Care Physician after collaboration with the PCP.
3. Medication is not an appropriate treatment for the symptom or diagnosis; or
4. Individual fails to participate in the medication regimen and repeated attempts at engagement, with at least one visit per month being documented or attempts to contact patient, do not result in patient participation or consent.

Group psychotherapy is a modality of treatment whereby participants utilize interactions with others, develop improved social skills, and have their needs met through acceptance, mutual support, help in overcoming maladaptive behavioral patterns, and facilitation of undistorted self-disclosure through the group process.  Group therapy emphasizes understanding and change of current behavioral patterns through opportunities for feedback and experience that are not available through individual modalities of treatment.  Group therapy typically consists of weekly one- to two-hour meetings of between two and ten participants.  Groups meeting more frequently than weekly and/or for more than two hours per session may be more appropriate for review under the criteria for Intensive Outpatient Programs. 

Group therapy programs and models may employ a variety of approaches, such as the following:

• 4308(a) Problem-focused group therapy, addressing such issues as grief and loss, work adjustment issues, and skills development for people with severe mental illnesses.
• 4308(b) Symptom-focused group therapy, whereby group sessions address an individual’s specific symptoms. Examples of this modality include anxiety/panic disorder education and support group; cognitive-behavioral treatment for depression; and education concerning specific mental illnesses and substance abuse disorders. 
• 4308(c) Group therapy for therapeutic stabilization can be especially useful for individuals with stable, long-term conditions, including those who need periodic professional monitoring or those who would benefit from a stable connection with a clinician but who may not attain therapeutic benefit and progress from traditional psychotherapy. The therapeutic stabilization group visits may combine medication management with some “check-in” group discussion so that the therapist can ensure that the individual is maintaining activities of daily living and adequate social activities.  These groups may be shorter than the standard group length of one and a half hours, depending on the functioning level of the group members and/or the size of the group. 
• 4308(d) Medication management groups can provide additional benefits through the interaction with peers in the group process. They should be distinguished from a medication clinic, where individuals are scheduled at the same time, but the psychiatrist/nurse meets with them individually for very brief sessions (often used for injections).  The medication management group, in addition to administering prescriptions or injections, must involve group discussion and education on illness (e.g., what leads to relapse, how to reduce stressors that lead to relapse, problems that may arise when alcohol use is combined with behavioral illness and behavioral medications), and mutual support groups (e.g., a mutual support group for individuals with severe mental illnesses would provide information on the types of resources available in order to facilitate the development of independent living skills or the maintenance of a social support network).
• 4.308(e) Long-term, specialized or focused groups providing group therapy may be an effective mode of treatment for individuals with personality disorders and significant dysfunctions (e.g., group treatment for people with bulimia; dialectical behavior therapy for individuals with personality disorders). Individuals requiring complex treatment may benefit most from group treatments that employ a defined structure to the entire program and course of treatment, as well as to the group therapy sessions; offer clearly defined goals, and assign “homework” or other structured activities to work on between sessions.

Procedures

Severity of Condition Criteria for Participation

Individuals are eligible for this level of care under the following conditions:

1. Individual presents with a DSM 5 or current DSM diagnosis.
2. Group therapy is preceded by an initial face-to-face assessment to determine the appropriateness of the group for the individual, as well as to educate him/her on group structure, group process, and expectations.
3. Some individuals may require preparation for group therapy beyond the initial assessment. That preparation may involve a course of three to five individual sessions to clarify the purpose of group therapy and to address issues raised by the consumer concerning referral to the group.  Individuals not receptive to group therapy after this preparation may be directed to individual therapy.
4. Individual is motivated for change or participates in the process actively or there is demonstrated potential to engage in treatment.
5. Individual’s cognitive abilities are intact, s/he can assume responsibility for behavioral change, and is capable of developing coping skills for long-term problem solving.

Intensity of Service and Continued Stay Criteria

An ongoing appraisal for the continued appropriateness of group therapy should include all of the following:

1. Group is led by a trained therapist, using specific techniques and theoretical constructs.
2. Open groups should be structured to accommodate new group members at every session or at regular intervals; closed group models may be preferable for individuals where the group process and interpersonal roles and relationships are the problem focus (e.g., groups dealing with relationship issues).
3. Multiple treatment modalities for the same problem or diagnosis (e.g., individual psychotherapy and group psychotherapy) must be considered in the context of a comprehensive treatment plan. For example:
   
   
   • Are both individual and group therapies treating the same issue from the same perspective?
   • Is the combined treatment complementary and would it hasten progress and/or enhance potential improvement?
   • Is the group and individual treatment provided by the same clinician or different clinicians?
   • What type of group is being offered?

Psychosocial Factors

Factors such as family dynamics, support system, financial and social need, homelessness, abuse/neglect, current or past trauma, unemployment or other social determinants of health may change the risk assessment and should be considered when making level of care placement decisions.

Exclusion Criteria

Any of the following criteria are sufficient for exclusion from this level of care:

1. Unable to participate in group sessions due to overriding symptoms of major psychiatric illness which prevent the individual from benefiting from this service.
2. Refusal to participate in the therapeutic process.

Discharge Criteria

Any of the following criteria are sufficient for discharge from this level of care:

1. Goals of therapy have been achieved.
2. Documented nonparticipation in treatment plan or
3. Movement to more intensive level of care.

Diagnostic evaluations are used to collect sufficient clinical data to determine the presence of a DSM 5 or current DSM diagnosis and/or need for services required for the optimum functioning of the individual.  At a minimum, this evaluation should consist of obtaining information from the individual, his/her family and/or support system, and other medical, psychiatric, substance abuse, and social history as available. This information should:

1. Establish the level of function;
2. Establish the diagnosis of a psychiatric and/or substance use disorder, if present;
3. Identify psychosocial and medical needs;
4. Define strengths and needs of the individual and availability of a support system; and
5. Provide enough data for development of treatment and service plans and alternatives and recommendations for treatment and services to aid the individual in recovery and rehabilitation.

For current recipients of services, a diagnostic evaluation is indicated when the individual’s level of function undergoes an acute change.  For those who have never had a diagnostic evaluation, indications that one may be needed include active psychiatric symptoms (e.g., hallucinations, social withdrawal, abnormally high or low levels of activity or energy); self destructive behavior; or acute changes in behavior not explained by other circumstances but which suggest an underlying psychiatric or social cause.  For those individuals who have a substance use disorder, the evaluation may be prompted by the individual’s request for services or the request for services by a family member or other involved individual. The request may also come from other treating professionals, legal authorities, members of the community and others. Repeat hospitalizations, work/school failure or poor performance, social withdrawal, suicide attempts, and/or difficulty in maintaining relationships may be a result of a psychiatric or substance use disorder or may reflect turmoil in the family or support setting.  If an evaluation has been completed in the past 30 days, either in an inpatient or outpatient setting, there is no need for a repeat evaluation unless symptoms or level of function have changed.

In order to assist the clinician in focusing their evaluation in a more effective way and to enhance the communication with reviewing clinicians, the evaluation should contain:

1. A review of presenting problem(s) or symptoms;
2. Psychiatric, social, and medical history;
3. Substance use history with particular focus on recent substance use and treatment;
4. Description of family/developmental history;
5. Thorough mental status exam;
6. Description of level of risk (suicidal/assaultive/homicidal), including specific examples of threats, plans, actions;
7. Level of function, GAF score, or other standard score or description;
8. Medical evaluation if medical history indicates an underlying medical disorder or if there is recent substance use or if the individual is requesting treatment for a substance use problem;
9. List of current treatment modalities, including medication;
10. Trauma History
11. Educational/Occupational history
12. History with the legal system
13. Diagnoses (DSM 5 or current DSM); and
14. Recommended treatment or service plan, including specific goals, discharge plan, and projected length of time or number of visits required, taking both clinical and psychosocial issues into account.

Intensive Outpatient Programs (IOP) provides time-limited, multidisciplinary, multimodal structured treatment in an outpatient setting.  Such programs are less intensive than a partial hospital program or day treatment (e.g., may not always include medical oversight and medication evaluation and management), but are significantly more intensive than outpatient psychotherapy and medication management.  Total clinical hours shall not exceed ten (10) hours per week.  Clinical interventions available should include modalities typically delivered in office-based settings such as individual, couple and family psychotherapy, group therapies, and psychoeducational services.  Adjunctive therapies, such as life planning skills (assistance with vocational, educational, financial issues) and special issue or expressive therapies may be provided, if they have a specific function within a given patient’s treatment plan.  Comprehensive treatment planning is individualized and appropriate to the individual’s changing condition with realistic and specific goals and objectives stated.  Treatment planning should include family or other support systems, social, occupational and interpersonal assessment with involvement when indicated. 

As functioning improves, the individual will receive a diminishing number of treatment hours.  All treatment plans must be individualized and should focus on acute stabilization and transition to community outpatient treatment and support groups as needed.  The environment must be sufficiently staffed to allow rapid professional assessment of a change in mental status which warrants a shift to a more intensive level of care or a change in medication.

Criteria

Admission Criteria

All of the following criteria are necessary for admission:

1. The individual demonstrates symptomatology consistent with a DSM 5 or current DSM diagnosis (IDD or SUD cannot stand alone)  which requires and can reasonably be expected to respond to therapeutic intervention.
2. There is an expectation that the individual will show significant progress toward treatment goals within the specified time frames as dictated by the individual treatment plan.
3. There are significant symptoms that interfere with the individual’s ability to function in at least one life area.
4. The individual’s condition requires a coordinated, office-based treatment plan of services, which may require integration and intensification of standard outpatient modalities and/or clinical disciplines for progress to occur.

Psychosocial, Occupational, and Cultural and Language Factors

These factors may change the risk assessment and should be considered when making level of care decisions and are reflected in the treatment planning process.

Exclusion Criteria

Any of the following criteria is sufficient for exclusion:

1. The individual is a danger to self and others or sufficient impairment exists that a more intensive level of service is required.
2. The individual has medical conditions or impairments that would prevent beneficial utilization of services.
3. The individual requires a level of structure and supervision beyond the scope of the program.
4. The individual can be safely maintained and effectively treated at a less intensive level of care.
5. The primary problem is social, economic, (i.e. housing, family, conflict, etc.), legal or one of physical health without concurrent significant symptoms related to the diagnosis specified in the admission criteria.
6. The individual or legal guardian does not voluntarily consent to admission or treatment and is not involuntarily committed to this level of care.

Continued Stay Criteria

All of the following criteria are necessary for continuing treatment:

1. The individual’s condition continues to meet admission criteria.
2. The individual’s treatment does not require a more intensive level of care, and no less intensive level of care would be appropriate.
3. Progress in relation to specific symptoms or impairments is clearly evident and can be described in objective terms, but goals of treatment have not yet been achieved. If lack of progress is evident, adjustments in the treatment plan are documented.
4. There is a documented active discharge planning, indicating that care is rendered in a clinically appropriate manner and focused on the individual’s behavioral and functional outcomes as described in the discharge plan.
5. The individual is motivated for continued treatment as evidenced by compliance with program rules and procedures.
6. There is a reasonable expectation based on the person’s clinical history that withdrawal of treatment will result in decompensation or recurrence of signs or symptoms.
7. The individual is an active participant in treatment and discharge planning.

Discharge Criteria

The following criteria are sufficient for discharge from this level of care:

There is a discharge plan with follow-up appointments in place prior to discharge.

And any of the following apply:

1. The individual’s documented treatment plan goals and objectives have been substantially met.
2. The individual no longer meets admission criteria or meets criteria for less or more intensive level of care.
3. The non-participation of the individual, family or legal guardian is of such a degree that treatment at this level is rendered ineffective or unsafe despite documented attempts to address non-participation issues.
4. Consent for treatment is withdrawn, and it is determined that the individual and/or legal guardian has the capacity to make an informed decision and the individual does not meet criteria for a higher or more restrictive level of care.
5. The individual is not making progress toward treatment goals and there is no reasonable expectation of progress at this level of care despite treatment planning changes and a recommendation is made for another level of care.

Clozaril is a drug of the anti-psychotic class which is used in the treatment of schizophrenia or other FDA approved indications in two situations: (1) For individuals with schizophrenia, or other FDA approved diagnoses, whose illness has been resistant to other first-line or novel anti-psychotic medications, and (2) for those individuals whose tolerance to previously used medications has been poor because of the side effects.

Due to the risk of developing agranulocytosis, a potentially fatal disease affecting the white blood cells, individuals using Clozaril are required to have their white blood cell count monitored for the duration of their treatment. This requirement does not necessitate weekly physician visits, however.  Early in treatment, while the medication is being titrated (or at any other time should the consumer’s status change), weekly or more frequent medication visits or longer sessions may be indicated depending on the patient’s condition. Following the stabilization of symptoms and dosage, weekly visits with the psychiatrist are not necessary to accomplish the required blood monitoring. The frequency and type of visits should be consistent with the individual’s clinical status and resultant need.

The required blood monitoring may be accomplished in a variety of ways. Patients participating in a program (e.g., PHP) may have their blood drawn at the program site and forwarded to a lab for analysis. Alternatively, patients may be referred to a local laboratory where the blood can be drawn and analyzed. However, the blood monitoring is managed, consumer education regarding risks associated with the use of Clozaril is essential to ensure adherence to the plan. Family education, when appropriate, is helpful as well. Support sessions with homogeneous groups of patients utilizing Clozaril, where available, can be another useful resource.

Severity of Condition Criteria for Placement

1. The individual must have a diagnosis of Schizophrenia, or a diagnosis that is an FDA approved indication for use of the drug.
2. Typically, the individual must have had symptoms that are resistant to other effective drugs, or the side effects of the other effective drugs were significant to the point that the disadvantages outweigh the advantages.
3. The individual must agree to the blood monitoring of the white blood cell count.
4. There must be a pharmacy or program which is participating in the Clozaril monitoring program
5. There must be a physician who is participating in the Clozaril (Clozapine) program

Intensity of Service and Continued Stay Criteria

1. Individual continues to participate in the blood-monitoring program.
2. The white blood count remains above 2000/ml

Psychosocial Factors

Not applicable

Exclusion Criteria

1. There has been a previous trial on Clozaril and the white blood cell count went below the minimum level.
2. Individual chooses not to participate in the blood monitoring program

Discharge Criteria

1. The individual develops low white blood cell count below the minimum established by the FDA.
2. The individual stops participating in the blood monitoring program
3. The individual wishes to disenroll from the program
4. The medication is not effective in controlling the symptoms
5. The side effects of Clozaril are intolerable for the individual

1. Initiation of ECT: All of the following criteria a and b, and c or d must be met:
   1. DSM or corresponding ICD diagnosis of major depression, schizophrenia, schizoaffective mood disorder, or other disorder with features that include mania, psychosis, and/or catatonia;
   2. Member has been medically cleared and there are no contraindications to ECT (i.e. Intracranial or cardiovascular, or pulmonary contraindications);
   3. There is immediate need for rapid, definitive response due to at least one of the following:
      1. Significant risk of harm to self or others;
      2. Catatonia;
      3. Intractable manic episode;
      4. Other treatment could potentially harm the member due to slower onset of action
   4. The benefits of ECT outweigh the risks of other treatments as evidenced by at least one of the following:
      1. Member has not responded to adequate medication trials;
      2. Member has had a history of positive response to ECT
2. Maintenance ECT: as indicated by all of the following:
   1. Without maintenance ECT member is at risk for relapse
   2. Adjunct therapy to pharmacotherapy

Acute inpatient mental health treatment represents the most intensive level of psychiatric care.  Multi-disciplinary assessments and multimodal interventions are provided in a 24-hour secure and protected, medically staffed, and psychiatrically-supervised treatment environment.  Typically, children/adolescents in need of such services display acute psychiatric conditions, which are associated with a relatively sudden onset and a short severe course, or a marked exacerbation of symptoms associated with a more persistent, recurring disorder.  Children/adolescents in need of this level of care may also pose a significant danger to themselves and/or others or to destruction of property.

Procedures

Severity of Condition Criteria for Admission

A child/adolescent is eligible for this level of care if s/he has been evaluated by a child and/adolescent psychiatrist (or Board Certified Psychiatrist) in the absence of  a Child and Adolescent Psychiatrist) within 24 hours of admission, and at least one of the following (1-8) is present and the child/adolescent cannot be treated at a less intense level of care:

1. A suicide attempt which is judged by the evaluating psychiatrist to be serious by degree of lethality and intentionality and is accompanied by feelings of hopelessness and helplessness.  Impulsive behavior and/or concurrent intoxication increase the need for consideration of this level of care;
2. Current assaultive threats or behavior which result from a severe mental illness or emotional and/or behavioral DSM 5 or current DSM  disorder and pose a clear risk of escalation or future repetition;
3. Current suicidal ideation that places the individual in "real and present danger" (e.g., has a plan and a means for suicide), particularly when accompanied by a DSM 5 or current DSM disorder;
4. Disordered/bizarre behavior or psychomotor agitation or retardation that interferes with the activities of daily living to such a degree that the individual cannot function at a lower level of care;
5. Disorientation or memory impairment that endangers the welfare of the individual or others when due to a DSM 5 or current DSM disorder;
6. Inability to maintain adequate nutrition or self care due to a psychiatric disorder^[2], and family/community support cannot be relied on to provide essential care;
7. Withdrawal from drugs or alcohol that necessitates a medical inpatient detoxification;
8. Severe, sustained, and pervasive inability to attend to age-appropriate responsibilities and/or severe deterioration of family and work/school functioning and no other level of care would be intensive enough to evaluate and treat the disorder.² And,
9. Reasonable documented treatment within a less restrictive setting has been provided by a mental health professional, and/or careful consideration of treatment within an environment less restrictive than that of a Psychiatric Inpatient Hospitalization, and the direct reasons for its rejection, have been documented

Note:  For those with a dual diagnosis of mental illness and substance abuse disorder, placement in a mental health program which is also credentialed to provide substance abuse services may be justified during acute withdrawal. 

Intensity of Service and Continued Stay Criteria

At least one of the following criteria must be necessary for continued treatment at this level of care:

1. Close and continuous skilled medical observation and supervision to make significant changes in psychotropic medication;
2. Continuous observation and control of behavior (e.g., isolation, restraining, other suicidal/homicidal precautions) to protect individual, others, and/or property;
3. Close and continuous skilled medical observation due to dangerous side effects (e.g., hypotension, arrhythmia) of psychotropic medication; or

A comprehensive multi-modal therapy plan requiring close supervision and coordination in a medical (psychiatric) setting.

Psychosocial Factors

Factors such as family dynamics, support system, financial and social need, homelessness, abuse/neglect, current or past trauma, unemployment or other social determinants of health may change the risk assessment and should be considered when making level of care placement decisions.

Exclusion Criteria

Any of the following criteria are sufficient for exclusion from this level of care:

1. Condition is diagnosed as long-term in nature requiring placement in a long-term facility;
2. Symptoms result from a medical condition which warrants a medical/surgical setting for treatment;
3. Child/adolescent can be effectively treated at a less intensive level of care.

Discharge Criteria

Any of the following criteria are sufficient for discharge from this level of care:

1. Treatment plan goals and objectives have been substantially met and symptoms, functional impairments and/or coexisting medical conditions that necessitated admission or continued have diminished in severity; or
2. No longer meets admission criteria or meets criteria for a less/more intensive level of care; or
3. Individual is non-participatory with treatment and/or no longer a danger to self/others, withdraws from treatment and does not meet criteria for involuntary commitment; and
4. There is a viable discharge plan which includes living arrangements and follow-up care; or
5. Acute physical condition necessitates transfer to a medical facility.
6. Transfer to a lesser level of care is unlikely to produce re-emergence of admission criteria.

Inpatient Sub-Acute treatment provides 24-hour services in a licensed, inpatient facility.  Children and adolescents receive therapeutic intervention and specialized programming in a controlled environment with a high degree of supervision.  Comprehensive services include multi-disciplinary, multi-modal therapies, as well as the use of community resources for planned, purposeful, and therapeutic activities that encourage residents’ autonomy.  Inpatient Sub-Acute treatment services are more intensive than partial hospitalization, RTF, or outpatient services.

Procedures

Severity of Condition Criteria for Admission

Children/adolescents are considered a candidate for this level of care if they do not meet acute criteria of Inpatient treatment and present with items “1” and “2” and “5” and 3 or 4:

1. Under the age of 22
2. Has a DSM 5 or current DSM diagnosis and the child's problematic behavior and/or severe functional impairment discussed in the presenting history and psychiatric/psychological examination must include at least one (1) of the following:
   1. Suicidal/homicidal ideation
   2. Impulsivity and/or aggression
   3. Psycho-physiological condition (i.e.- bulimia, anorexia nervosa)
   4. Psychomotor retardation or excitation.
   5. Affect/Function impairment (i.e.- withdrawn, reclusive, labile, reactivity)
   6. Psychosocial functional impairment
   7. Thought Impairment
   8. Cognitive Impairment and
3. Family situation and dynamics are such that the child/adolescent cannot currently remain with his/her biological or adoptive family;
4. Disturbances/behaviors/symptoms are such that treatment cannot be successfully provided in a lower level of care;
5. Placement in a less restrictive and clinically appropriate setting, e.g., RTF or CRR, is pending. Following PA School Code, Sections 1306-1309 and 2561, when a child is removed from the school setting for the purpose of receiving mental health treatment, it is expected that the appropriate school system will be involved in the child's educational planning and the interagency team. In the event that conditions prevent the possibility of parental or child involvement, attempts to involve the child and parents and/or reasons explaining their non-involvement must be fully documented and presented to an interagency team (from Appendix T, Part B (1)).

Therapeutic Residential Care/CRR is the provision of services 24-hours a day to children/adolescents in an appropriately  licensed facility by adults who have been specifically trained to care for children/adolescents with serious emotional disorders.

Procedures

Severity of Condition Criteria for Admission

All of the following criteria are necessary for admission to this level of care:

1. Child/adolescent is under the age of 21;
2. Functional levels are such that the child/adolescent cannot currently remain with his/her biological or adoptive family;
3. Child/adolescent exhibits behaviors severe enough to warrant specialized behavioral care;
4. Child/adolescent has a psychiatric diagnosis and presents a moderate danger to self or others as indicated by assaultive or unpredictable behavior or other risk taking, impulsive behavior;
5. Any addictions or psychotic symptoms have been stabilized; and
6. Child/adolescent has been recently released or is being diverted from intensive residential treatment, observation/stabilization services, inpatient psychiatric hospitalization, or inpatient drug and alcohol services.

Intensity of Service and Continued Stay Criteria

All of the following criteria are necessary for continued stay in this level of care;

1. Severity of symptoms and behavior is such that the child/adolescent continues to require this level of care and based on the history, there is reasonable expectation that removal to a lower level of care would result in a decompensation or recurrence of signs or symptoms or regression of behavior.
2. Family dynamics or support system remains a barrier to return to that environment; and
3. Other desired placement is not available at this time.

Psychosocial Factors

These factors, as detailed in Section 2.10, may change the risk assessment and should be considered when making level of care placement decisions.

Exclusion Criteria

Any of the following criteria are sufficient for a child/adolescent’s exclusion from this level of care:

1. Expresses or represents a serious threat of harm to self or others to the extent that a more secure environment is needed;
2. Addicted to alcohol or other drugs;
3. Exhibits signs and symptoms of a major psychiatric illness that requires a more intensive setting; or
4. Requires placement in a medical setting that requires constant monitoring.

Discharge Criteria

Any of the following criteria are sufficient for discharge from this level of care if a viable discharge plan is in place which addresses living arrangements and includes follow-up care and/or transfer to a lesser level of care is unlikely to produce re-emergence of admission criteria:

1. Returns to live with parents/guardian/other;
2. Treatment goals have been achieved and the child/adolescent is able to function in a lower level of care;
3. Exhibits severely disruptive or dangerous behaviors (such as suicide or homicide attempt, drug addiction, or symptoms of psychosis) that require immediate attention in a more highly structured or clinical setting.

Outpatient treatment usually is an individualized mode of treatment which may occur in a clinic setting or in the offices of a private practitioner. It involves the interaction between a therapist and child/adolescent in order to resolve an identified problem in daily living (problem-focused) or symptoms resulting from non-adaptive thoughts, feelings, interpersonal disturbances, and/or experiences.  The approach is often educational in nature and directed toward identifying and utilizing available resources.  The goal is to restore and enhance the child/adolescent’s capacity to find solutions.  In addition to the consumer, family members or other caregivers may participate in this level of care.  The problems identified may be recurrent in nature (e.g., those identified by individuals with a persistent recurring mental illness or substance use diagnosis) or may be a newly identified problem in an individual who has previously experienced a higher level of function. These identified problems may become     the focus of the treatment episode. Typically, problem-focused, symptom-focused and evidenced based  treatment entails distinct, brief episodes of problem solving, as well as building positive coping skills with discharge when the child/adolescent is stable, unless there are strong indications that this level of care must be continued in order to maintain the stability already achieved.  In the clinic setting, many other services may be utilized in coordination with the individual therapy to complement the effect of the treatment. When the child/adolescent is discharged there must be the assurance that s/he can return to treatment should additional problems arise.

Procedures

Severity of Condition Criteria for Participation

For each episode of treatment, clinical necessity exists when all of the following conditions are met:

1. There is a clearly identified problem or symptom resulting from a DSM-5 diagnosis
2. The individual is able to actively participate in the treatment with guidance and support.

Intensity of Service and Continued Stay Criteria

All of the following criteria are necessary for continued stay in this level of care:

1. The therapist and consumer or family meet in a face-to-face encounter(s) or via telehealth;
2. Identified problem and/or symptomatology and action plan or withdrawal of treatment will result in decompensation or recurrence of symptoms;
3. Assessment for further symptom and/or diagnosis identification;
4. Rule out need for more intense levels of service, including substance use treatment;
5. Precise documentation of all sessions, assessments, treatment plans, and interventions.

Psychosocial Factors

Factors such as family dynamics, support system, financial and social need, homelessness, abuse/neglect, current or past trauma, unemployment or other social determinants of health may change the risk assessment and should be considered when making level of care placement decisions.

Exclusion Criteria

N/A

Discharge Criteria

Any of the following criteria are sufficient for discharge from this level of care:

1. Goals of therapy have been achieved.
2. Clear and detailed documentation of non-participation after multiple attempts at engagement, are noted within treatment plan.
3. Movement to more intensive level of care.

Non-acute partial hospitalization is a nonresidential treatment program that may be hospital, community or school based.  The program provides clinical diagnostic and treatment services on a level of intensity less than acute partial hospitalization but more intensive than traditional outpatient services.  These services may include therapeutic milieu, nursing, psychiatric evaluation and medication management, group and individual/family therapy, psychological testing, pre-vocational counseling, academic, substance use education, prevention, assessment, referral and treatment planning.  However, these services require less intensive individual intervention for symptom management than in an acute partial hospitalization program.

The environment at this level of treatment is highly structured. The staff-to-patient ratio will be sufficient to ensure necessary therapeutic services, professional monitoring, and protection. . The partial staff ratio should follow minimum standards set forth in Pennsylvania state regulations Title 55. Chapter 5210 Partial Hospitalization section 5210.31 that are 1 FTE for every 5 patients Non-acute psychiatric partial hospital treatment may be appropriate when a patient does not require the more restrictive and intensive environment of a 24-hour inpatient setting and/or acute partial hospitalization, with no less than three (3) hours of clinical services per day with the expectation that services are provided no less than 3.5 days per week. 

Non-acute partial hospitalization is used for stabilization and treatment of individuals who require more intensive services than are provided in outpatient or aftercare programs.  As such, is can be used both as a transitional level of care (i.e., step-down from inpatient) as well as a stand-alone level of care to stabilize a deteriorating condition and avert utilization of a higher level of care. Beacon Pa certification guidelines (Policy CN.23) indicates precertification up to 8 weeks and continued stay up to 8 weeks.   

Treatment efforts need to focus on the individual’s response during treatment program hours, as well as the continuity and transfer of treatment gains during the individual’s non-program hours in the home/school/community.  Comprehensive treatment planning is individualized and appropriate to the individual’s changing condition with realistic and specific goals and objectives stated.  Treatment planning should include active family or other support systems, social, educational and interpersonal assessment with involvement when indicated. 

Non-acute psychiatric partial hospital treatment is separate and distinct from acute partial hospitalization program (see CL 14.103) based on the level of intensity of the services as indicated by length of stay, number of days of attendance per week, individual program description and Beacon Pa certification guidelines policy number CN.23.

Criteria

Admission Criteria

All of the following criteria are necessary for admission:

1. The individual is age 17 or under OR if between the ages of 18-21, either of the following must apply:
   
   
   • Is enrolled as a Full-Time student in High School, Secondary Education and/or Vocational Technical Training.
   • Is in the custody of Children and Youth Services
2. The individual demonstrates symptomatology consistent with a DSM 5 or current DSM (IDD or SUD cannot stand alone) diagnosis by a psychiatrist or psychologist that requires and can reasonably be expected to respond to therapeutic intervention.
3. Non-acute partial hospitalization must be recommended as the most clinically appropriate and least restrictive service available for the child by the treatment team which shall include the child, parent/guardian and/or caretaker and case manager.
4. There is evidence of the individual’s capacity and support for reliable attendance at the non-acute partial hospitalization program.
5. There is an adequate social support system available to provide the stability necessary for the individual’s maintenance in the program OR the individual demonstrates the capacity to assume responsibility for their safety outside program hours.
6. The individual’s risk to self, others, or property is not so serious as to require 24-hour medical/nursing supervision or the intensity of an acute partial hospitalization program. The individual does require structure and supervision for a significant portion of the day and family/community support when away from the non-acute partial hospitalization program.
7. The individual’s condition requires a comprehensive, multi-disciplinary, multi-modal course of treatment. This includes routine medical observation/supervision to effect significant regulation of medication and/or routine nursing observation and behavioral intervention to maximize functioning and minimize risks to self, others and property.

Psychological testing involves the culturally and linguistically competent administration and interpretation of standardized tests to assess an individual’s psychological or cognitive functioning.  Testing is viewed as a potentially helpful second opinion when standardized diagnostic interviewing or therapeutic procedures are unable to sufficiently address the diagnostic or treatment related issues.

Criteria

Admission Criteria

Psychological Testing

Either 1, 2, or 3

1. Testing is needed for a differential diagnosis of a covered mental health condition, which is not clear from a traditional assessment (i.e., clinical interview, and brief rating scales), and diagnostic clarity is needed for effective psychotherapy or psychopharmacotherapy treatment planning.
2. The individual has not responded to standard treatment with no clear explanation of treatment failure, and testing will have a timely effect on the individual treatment plan.
3. When a case can be made for the need of in-depth analysis of case conceptualization, such as in, but not limited to, complex cases.

Neuropsychological Testing

1. Neuropsychological testing should only be requested after a comprehensive psychological/psychiatric evaluation and a recommendation by a licensed psychologist, psychiatrist, or neurologist.
   
   Either 2 , 3, 4, or 5

2. Testing is needed for a differential diagnosis, which is not clear from a traditional assessment (i.e., clinical interview, and brief rating scales), and diagnostic clarity is needed for effective psychotherapy or psychopharmacotherapy treatment planning.
3. The individual has not responded to standard treatment with no clear explanation of treatment failure, and testing will have a timely effect on the individual treatment plan.
4. Mapping out brain dysfunction and identifying pathways for cognitive rehabilitation are critical to the development of a behavioral health treatment plan.
5. When a case can be made for the need of in-depth analysis of case conceptualization, such as in, but not limited to, complex cases.

Exclusion Criteria

1. Testing was administered within the last year, and there is no strong evidence that the patient’s situation or functioning is significantly different.
2. Testing is primarily for educational purposes.
3. Testing is requested within 30 days of active substance abuse.
4. Testing is primarily to guide the titration of medication.
5. Testing is primarily for legal purposes.
6. Testing is primarily for medical guidance, cognitive rehabilitation, or vocational guidance, as opposed to the admission criteria purposes stated above.
7. Testing request appears more routine than medically necessary (e.g., a standard test battery administered to all new patients).
8. Specialized training by provider is not demonstrated.
9. Interpretation and supervision of neuropsychological testing (excluding the        administration of tests) is performed by someone other than a licensed psychologist with a specialty in neuropsychology.
10. Measures proposed have no standardized norms or documented validity.
11. The time requested for a test/test battery falls outside Beacon Health Options established time parameters (and no clinical rationale was provided to justify a longer time period).
12. Extended testing for ADHD has been requested prior to provision of a thorough evaluation, which has included a developmental history of symptoms and administration of rating scales.
13. Symptoms of acute psychosis, confusion, disorientation, etc., interfering with proposed testing validity are present.
14. Administration, scoring and/or reporting of projective testing is performed by someone other than a fully licensed psychologist or other mental health professional whose scope of training and licensure includes such testing.

Continued Stay Criteria

Does not apply.

Discharge Criteria

Does not apply.

Group psychotherapy is a modality of treatment whereby participants utilize interactions with others, develop improved social skills and their needs are met through acceptance, mutual support, help in overcoming maladaptive behavioral patterns, and facilitation of undistorted self-disclosure facilitated in the group process.  Group therapy emphasizes understanding and change of current behavioral patterns through opportunities for feedback and experience that are not available through individual modalities of treatment.  Group therapy typically consists of weekly meetings of between four and ten participants.  Sessions are usually one to two hours in length.  Groups meeting more frequently than weekly and/or for more than two hours per session may be more appropriate for review under the criteria for Intensive Outpatient Programs.

Group therapy programs and models may employ a variety of approaches, such as the following:

• 404(a) Problem-focused group therapy, addressing such issues as grief and loss, work adjustment issues, and skills development for people with severe mental illnesses.
• 404(b) Symptom-focused group therapy, whereby group sessions address an individual’s specific symptoms. Examples of this modality include anxiety/panic disorder education and support group; cognitive-behavioral treatment for depression; and education concerning specific mental illnesses and substance abuse disorders. 
• 404(c) Group therapy for therapeutic stabilization can be especially useful for individuals with stable, long-term conditions, including those who need periodic professional monitoring or those who would benefit from a stable connection with a clinician but who may not attain therapeutic benefit and progress from traditional psychotherapy. The therapeutic stabilization group visits may combine medication management with some “check-in” group discussion so that the therapist can ensure that the individual is maintaining activities of daily living and adequate social activities.  These groups may be shorter than the standard group length of one and a half hours, depending on the functioning level of the group members and/or the size of the group. 
• 404(d) Medication management groups can provide additional support and improve participation and therapeutic benefit for selected individuals. They should be distinguished from a medication clinic, where individuals are scheduled at the same time, but the psychiatrist/nurse meets with them individually for very brief sessions (often used for injections).  The medication management group, in addition to administering prescriptions or injections, must involve group discussion and education on illness (e.g., what leads to relapse, how to reduce stressors that lead to relapse, problems that may arise when alcohol use is combined with behavioral illness and behavioral medications), and mutual support groups (e.g., a mutual support group for individuals with severe mental illnesses would provide information on the types of resources available in order to facilitate the development of independent living skills or the maintenance of a social support network).
• 6.404(e) Long-term, specialized or focused groups providing group therapy may be an effective mode of treatment for individuals with personality disorders and significant dysfunctions (e.g., group treatment for people with bulimia; dialectical behavior therapy for individuals with personality disorders).   Individuals requiring complex treatment may benefit most from group treatments that employ a defined structure to the entire program and course of treatment, as well as to the group therapy sessions; offer clearly defined goals, and assign “homework” or other structured activities to work on between sessions.

Procedures

Severity of Condition Criteria for Participation

Individuals are eligible for this level of care under the following conditions:

1. Individual presents with a DSM 5 or current DSM diagnosis.
2. Group therapy is preceded by an initial face-to-face assessment to determine the appropriateness of the group for the individual, as well as to educate him/her on group structure, group process, and expectations.
3. Some individuals may require preparation for group therapy beyond the initial assessment. That preparation may involve a course of 3-5 individual sessions to clarify the purpose of group therapy and to address issues the individual raises about referral to the group.  Individuals not receptive to group therapy after this preparation may be directed to individual therapy.
4. Individual is motivated for change or is likely to become engaged in this treatment.
5. Individual’s cognitive abilities are intact, s/he can assume responsibility for behavioral change, and is capable of developing coping skills for long-term problem solving.

Intensity of Service and Continued Stay Criteria

A ongoing appraisal of the continued need for this service should include all of the following:

1. Group is led by a trained therapist, using specific techniques and theoretical constructs.
2. All sessions, treatment plans, and interventions are documented.
3. Open groups should be structured to accommodate new group members at every session or at regular intervals; closed group models may be preferable for individuals where the group process and interpersonal roles and relationships are the problem focus (e.g., groups dealing with relationship issues).
4. Multiple treatment modalities for the same problem or diagnosis (e.g., individual psychotherapy and group psychotherapy) must be considered in the context of a comprehensive treatment plan. For example:
   • Are both individual and group therapies treating the same issue from the same perspective?
   • Is the combined treatment complementary and would it hasten progress and/or enhance potential improvement?
   • Are the group and individual treatment provided by the same clinician or different clinicians?
   • What type of group is being offered?

Psychosocial Factors

Factors such as family dynamics, support system, financial and social need, homelessness, abuse/neglect, current or past trauma, unemployment or other social determinants of health may change the risk assessment and should be considered when making level of care placement decisions.

Exclusion Criteria

Any of the following criteria are sufficient for exclusion from this level of care:

1. Unable to participate in group sessions due to overriding symptoms of major psychiatric illness;
2. Chooses not to participate in the therapeutic process and is judged to be unlikely to become engaged after clinical evaluation and observation.

Discharge Criteria

Any of the following criteria are sufficient for discharge from this level of care:

1. Goals of therapy have been achieved;
2. Documented non-participation in treatment plan and is not court ordered to participate in this treatment; or
3. Movement to more intensive level of care.

Family therapy is conducted with the child/adolescent, parents/caregivers, and siblings (as indicated) in order to reduce symptomatology and integrate the child/adolescent’s treatment goals into the family unit. Family members are assisted with identifying and maximizing their strengths they bring to the treatment process. The family unit works collaboratively with the treatment provider to develop problem-solving techniques. Patterns of behavior and communication are assessed and addressed, as necessary. Family treatment should be part of a child/adolescent’s treatment plan unless this modality is contraindicated for reasons of emotional or physical safety. Family is defined as but not limited to the identified support system by both the child/adolescent and parent/caregivers.

Procedures

Severity of Condition Criteria for Participation

Clinical necessity exists when any the following conditions are met:

1. Child/adolescent’s symptoms ,may potentially be reduced as a result of family therapy;
2. This level of care is necessary in order to integrate the child/adolescent’s treatment goals into the family unit;
3. Family relationships are identified as problematic;
4. Child/adolescent has observed difficulty with parental authority; or
5. Child/adolescent and family need assistance with changes in behavior associated with safety risks associated with SI/SIB, truancy, substance use, delinquency, and issues of abuse/neglect.

Intensity of Service and Continued Stay Criteria

All of the following are necessary to continue to meet clinical necessity:

1. Child/adolescent and the family are appropriately participating; and
2. Treatment plan is documented to address:
   1. Family’s strengths;
   2. Family issues to be resolved;
   3. Specific intervention to be used; and
   4. Length of treatment.

Psychosocial Factors

Factors such as family dynamics, support system, financial and social need, homelessness, abuse/neglect, current or past trauma, unemployment or other social determinants of health may change the risk assessment and should be considered when making level of care placement decisions.

Exclusion Criteria

The following criterion is sufficient for exclusion from this level of care.

1. The child/adolescent or family chooses not to participate in this intervention and there have been at least three attempts to engage the family and child/adolescent without success.

Discharge Criteria

Any of the following criteria are sufficient for discharge from this level of care:

1. All identified treatment goals have been met; or
2. The child/adolescent or family member chooses not to participate with the mutually developed and agreed upon treatment plan and,
3. Attempts to engage the family and child/adolescent have been unsuccessful and all attempts are carefully documented.

6.406a Medication management by a physician applies to situations in which the sole service rendered by a qualified physician is the evaluation of an individual’s need for psychotropic drugs, the provision of a prescription, education of the consumer and parent/guardian and ongoing medical monitoring.  For certain individuals, medication management will continue beyond the psychotherapy component of treatment.  For others, medication management will occur in the context of long-term supportive psychotherapy.  Interactive psychotherapy is not rendered by the physician during medication management but may be provided by another clinician.  Medication management is classified into one of two categories:

1. Providing medical supervision and prescribing or evaluating the need for psychotropic drugs to an individual who is in treatment with a non-medical psychotherapist; or
2. Providing medical services, including prescription of psychotropic drugs, to an individual not currently in need of psychotherapy.

6.406b Medication Management by a licensed nurse. This service is provided by a nurse who works under the supervision of a physician in monitoring the drug dosage, side effects and effects of the medication, as well as compliance, weight, nutritional status (especially with children), vital signs.  There is also the capability to collect blood and urine samples for drug monitoring and monitoring of the health status. These visits may be weekly or more or less frequent as needed for these functions and will be coordinated with the regular Physician Medication Management visits and with the Primary Care Physician. A certified registered nurse practitioner (CRNP) additionally may diagnose, prescribe and formulate a treatment plan within the scope of licensure in Pennsylvania.

6.406c Medication Management by a Physician Assistant. This service is provided by a Physician Assistant (PA), working under the supervision of a physician, who can monitor the side effects, drug dosage and effectiveness of medications and actively prescribe within the scope of licensure of Pennsylvania.

6.406d. Medication management groups can provide additional support and improve participation and therapeutic benefit for selected individuals. They should be distinguished from a medication clinic, where individuals are scheduled at the same time but the psychiatrist/nurse meets with them individually for very brief sessions (often used for injections).  The medication management group, in addition to administering prescriptions or injections, must involve: group discussion and education on illness (e.g., what leads to relapse, how to reduce stressors that lead to relapse, problems that may arise when alcohol use is combined with behavioral illness and behavioral medications), mutual support group (e.g., for individuals with severe mental illnesses, the types of resources are available to them for the development of skills around living independently, and maintaining social support network).

Procedures

Severity of Condition Criteria for Participation

Clinical necessity exists under the following conditions:

1. A problem has been identified which is expected to respond to medication; and
2. The child/adolescent needs to be evaluated for medication use, obtain a prescription, or (for those currently taking psychotropic medication/s) be medically monitored.

Intensity of Service and Continued Stay Criteria

All of the following are necessary to continue to meet clinical necessity:

1. The medication or other medical service is prescribed by a qualified physician, preferably a psychiatrist (non-psychiatrist where psychiatrist is not available, such as in rural areas);
2. The physician providing the prescription or medical service is not the consumer’s therapist;
3. The physician meets face-to-face with the child/adolescent, on a scheduled basis:
   1. For individual with acute needs who is not yet stabilized or is experiencing adverse side effects, meetings occur as clinically necessary for monitoring and dosage adjustment;
   2. Physician meets once a month or, at a minimum of once every three months, or as otherwise clinically indicated, with a child/adolescent who is stabilized or has long-term needs, if the pharmacological plan is appropriate and s/he is not experiencing complications from the medication(s); and
4. The physician collaborates with a psychotherapist or treatment team, if one exists, and the primary care provider when the prescription is renewed or changed.

Psychosocial actors

Factors such as family dynamics, support system, financial and social need, homelessness, abuse/neglect, current or past trauma, unemployment or other social determinants of health may change the risk assessment and should be considered when making level of care decisions.

Exclusion Criteria

The following criterion is sufficient for exclusion from this level of care.

1. Child/adolescent refuses to participate in medication management.

Discharge Criteria

Any of the following criteria are sufficient for discharge from this level of care:

1. Medication is discontinued as a result of individual’s choice to refuse medication use;
2. Medication is not an appropriate treatment for the symptom or diagnosis; or
3. Individual fails to participate in the medication regimen and repeated attempts at engagement, with at least one visit per month being documented or attempts to contact patient, do not result in patient participation or consent.

Diagnostic evaluations are used to collect sufficient clinical data to determine the presence of a DSM 5 or current DSM diagnosis and/or need for services required for the optimum functioning of the individual.  At a minimum, this evaluation should consist of obtaining information from the individual, his/her family and/or support system, and other medical, psychiatric, substance abuse, and social history as available. This information should:

1. Establish the level of function;
2. Establish the diagnosis of a psychiatric and/or substance use disorder, if present;
3. Identify psychosocial and medical needs;
4. Define strengths and needs of the individual and availability of a support system; and
5. Provide enough data for development of treatment and service plans and alternatives and recommendations for treatment and services to aid the individual in recovery and rehabilitation.

For current recipients of services, a diagnostic evaluation is indicated when the individual’s level of function undergoes an acute change.  For those who have never had a diagnostic evaluation, indications that one may be needed include active psychiatric symptoms (e.g., hallucinations, social withdrawal, abnormally high or low levels of activity or energy); self destructive behavior; or acute changes in behavior not explained by other circumstances but which suggest an underlying psychiatric or social cause.  For those individuals who have a substance use disorder, the evaluation may be prompted by the individual’s request for services or the request for services by a family member or other involved individual. The request may also come from other treating professionals, legal authorities, members of the community and others. Repeat hospitalizations, work/school failure or poor performance, social withdrawal, suicide attempts, and/or difficulty in maintaining relationships may be a result of a psychiatric or substance use disorder or may reflect turmoil in the family or support setting.  If an evaluation has been completed in the past 30 days, either in an inpatient or outpatient setting, there is no need for a repeat evaluation unless symptoms or level of function have changed.

The evaluation should contain:

1. A review of presenting problem(s) or symptoms;
2. Psychiatric, social, and medical history;
3. Substance use history with particular focus on recent substance use and treatment;
4. Description of family/developmental history;
5. Thorough mental status exam;
6. Description of level of risk (suicidal/assaultive/homicidal), including specific examples of threats, plans, actions;
7. Level of function, GAF score, or other standard score or description;
8. Trauma History
9. History of involvement in the legal system
10. Educational history
11. Medical evaluation if medical history indicates an underlying medical disorder or if there is recent substance use or if the individual is requesting treatment for a substance use problem;
12. List of current treatment modalities, including medication;
13. Diagnoses (DSM 5 or current DSM); and
14. Recommended treatment or service plan, including specific goals, discharge plan, and projected length of time or number of visits required, taking both clinical and psychosocial issues into account.

Intensive Outpatient Programs (IOP) for children/adolescents provides time-limited, multidisciplinary, multimodal structured treatment in an outpatient setting. Such programs are less intensive than a partial hospital program (e.g., may not always include medical oversight and medication evaluation and management as a PHP would), but are more intensive than outpatient psychotherapy and medication management. Total clinical hours shall not exceed ten (10) hours per week. Clinical interventions available should include modalities typically delivered in office-based settings, such as individual, family psychotherapy, group therapies, evidence based practices and psychoeducational services. Family involvement from the beginning of treatment is extremely important and, unless contraindicated should occur at least once weekly. Adjunctive therapies, such as life planning skills (assistance with vocational, educational, financial issues) and expressive therapies may be provided, if they have a specific function within a given patient’s treatment plan. Assessment of school performance is an important component of treatment planning, as is involvement with school personnel to monitor the ongoing impact of treatment and facilitate constructive ways of working with children/adolescents across multiple life domains. Comprehensive treatment planning is individualized and appropriate to the individual’s changing condition with realistic and specific goals and objectives stated. Treatment planning should include family or support systems, social, educational and interpersonal assessment with involvement when indicated.

As functioning improves, the individual will receive a diminishing number of treatment hours. All treatment plans must be individualized and should focus on acute stabilization and transition to community outpatient treatment and support groups as needed. 

Criteria

Admission Criteria

All of the following criteria are necessary for admission:

1. The individual demonstrates symptomatology consistent with a DSM 5 (IDD or SUD cannot stand alone) diagnosis that requires and can reasonably be expected to respond to therapeutic intervention.
2. There is an expectation that the individual will show significant progress toward treatment goals within the specified time frames as dictated by the individual treatment plan.
3. There are significant symptoms that interfere with the individual’s ability to function in at least one life area.
4. The individual’s condition requires a coordinated, office-based treatment plan of services, which may require integration and intensification of standard outpatient modalities and/or clinical disciplines for progress to occur.

Psychosocial, Academic, Cultural and Language Factors

Factors such as family dynamics, support system, financial and social need, homelessness, abuse/neglect, current or past trauma, unemployment or other social determinants of health may change the risk assessment and should be considered when making level of care placement decisions.

Exclusion Criteria

Any of the following criteria is sufficient for exclusion:

1. The individual is a danger to self and others, or sufficient impairment exists that a more intensive level of service is required.
2. The individual requires a level of structure and supervision beyond the scope of the program.
3. The individual can be safely maintained and effectively treated at a less intensive level of care.
4. The primary problem is social, economic, (i.e. housing, family, conflict, etc.), legal without concurrent significant symptoms related to diagnosis as specified in the admission criteria.
5. The individual or legal guardian does not voluntarily consent to admission or treatment and is not involuntarily committed to this level of care.

Continued Stay Criteria

All of the following criteria are necessary for continuing treatment:

1. The individual’s condition continues to meet admission criteria.
2. The individual’s treatment does not require a more intensive level of care, and no less intensive level of care would be appropriate.
3. Progress in relation to specific symptoms or impairments is clearly evident, and can be described in objective terms, but goals of treatment have not yet been achieved. If lack of progress is evident adjustments in the treatment plan are documented.
4. There is documented active discharge planning, indicating that care is rendered in a clinically appropriate manner and focused on the individual’s behavioral and functional outcomes as described in the discharge
5. The individual is motivated for continued treatment as evidenced by compliance with program rules and procedures.
6. There is reasonable expectation based on the person’s clinical history that withdrawal of treatment will result in decompensation or recurrence of signs or symptoms.
7. The individual, parent/guardian and/or caretaker are active participants in treatment and discharge planning.

Discharge Criteria

The following criteria are sufficient for discharge from this level of care:

There is a discharge plan with follow-up appointments in place prior to discharge.

And any of the following apply:

1. The individual’s documented treatment plan goals and objectives have been substantially met.
2. The individual no longer meets admission criteria or meets criteria for less or more intensive level of care.
3. The non-participation of the individual, family or legal guardian is of such a degree that treatment at this level is rendered ineffective or unsafe despite documented attempts to address non-participation issues.
4. Consent for treatment is withdrawn, and it determined that the individual, parent/guardian and/or caretaker have the capacity to make an informed decision and the individual does not meet criteria for a higher or more restrictive level of care.
5. The individual is not making progress toward treatment goals and there is no reasonable expectation of progress at this level of care despite treatment planning changes and a recommendation is made for another level of care.

The Long Term Structured Residence (LTSR) provides twenty-four (24) hour services in a structured setting for individuals who have demonstrated severe and persistent psychiatric disorders and can reasonably be expected to respond to therapeutic intervention. The facility is licensed and secure.  Individuals receive therapeutic intervention and specialized programming in a controlled environment with a high degree of supervision in a structured milieu. The program addresses the identified problems through a wide range of diagnostic and treatment services as well as through rehabilitative training in basic skills such as social, problem solving, and activities of daily living in the context of a comprehensive multidisciplinary treatment plan. This level of care requires at least weekly psychiatrist visits in addition to providing psychosocial and rehabilitative training with focus on reintegration to a less restrictive setting. Each individual will have an individualized rehabilitative treatment plan which is strength based, consumer recovery oriented, flexible and inclusive of family/natural supports.

Criteria

Admission Criteria

All of the following criteria are necessary for admission to the LTSR:

1. An individual must be 18 years of age or older.
2. An individual qualifies for voluntary treatment under section 201 of the act (50 P.S. § 7201), or involuntary treatment under section 304,305, or 306 of the act (50 P.S. § 7304-7306).
3. An individual is not sufficiently stable to be treated outside of a highly structured, secured, 24-hour therapeutic environment as evidenced by a physician’s certification that the individual is eligible for, but does not require, hospitalization, skilled nursing facility, or a level of care more restrictive than an LTSR.
4. There is evidence of a severe psychosocial disability as a result of a serious mental illness consistent with a DSM 5 or current DSM diagnosis that indicates a less restrictive level of care is inappropriate.
5. The individual can reasonably be expected to respond to therapeutic intervention.
6. The individual has:
   1. A history of multiple inpatient hospitalization
      and/ or
   2. Current inpatient hospitalization
      and/ or
   3. Current or history of public mental hospital (state hospital) placement
      and/ or
   4. A history of other treatment episodes with poor treatment adherence or treatment outcomes.
7. The individual lacks supports sufficiently needed to maintain him/her in a less restrictive community setting.
8. The individual must have a physical examination and psychiatric evaluation no more than 6 months prior to admission to the LTSR and a written psychiatric certification of the need for the services within 30 days prior to admission.
9. The individual’s comprehensive needs assessment will include the mental, physical and social needs prior to admission.

Exclusion Criteria

Any of the following criteria is sufficient for exclusion from this level of care.

1. The individual exhibits severe homicidal, suicidal, or acute mood symptoms/thought disorder, which requires a more intensive level of care.
2. The individual can be safely maintained and effectively treated at a less intensive level of care.
3. The individual has medical impairments that would prevent beneficial utilization of services.
4. The primary problem is a social, economic (i.e. housing, family conflict, etc.), legal, sexual offense(s), substance use, organicity, or intellectual disability.
5. Pursuant to 55 Pa. Code § 5320.54, the individual requires restraint and/or seclusion.

Continued Stay Criteria

All of the following criteria are necessary for continuing treatment at this level of care.

1. The individual’s condition continues to meet admission criteria at this level of care.
2. Progress in relation to specific symptoms or impairments is clearly evident and can be described in objective terms, but goals of treatment have not yet been achieved or adjustments in the treatment plan to address lack of progress are evident.
3. The individual’s treatment does not require a more intensive level of care and no less intensive level of care would be appropriate.
4. Discharge planning is ongoing which includes all of the following:
   1. Is evaluated according to minimal standards set forth by Chapter 5320 at multidisciplinary team meeting at least every 30 days or as clinically indicated.        
   2. The discharge planning includes documented involvement of the individual inclusive of family/natural supports with the individual’s consent.

Discharge Criteria

At least one of the following is sufficient for discharge from this level of care:

1. Consent for voluntary treatment is withdrawn.
2. The individual no longer meets criteria for this level of care, or meets criteria for a less or more intensive level of care.
3. The individual’s documented treatment plan goals and objectives have been substantially met, and/or a safe, continuing care program can be arranged and deployed at an alternative level of care.

AND one of the following:

1. Support systems, which allow the individual to be maintained in a less restrictive environment, have been thoroughly explored and/or secured.
2. The individual is not making progress toward treatment goals, and there is no reasonable expectation for progress at this level of care.

Intensive Case Management (ICM) is the organized approach to coordinating segments of a service delivery system in order to ensure the most comprehensive process for meeting an individual client ‘s needs for care .  Clients with complex, multiple problems will receive needed individualized services in a coordinated fashion at the time they are needed.  Case management provides evaluation of the client’s strengths and needs, service planning and goal setting, linking, implementing, monitoring, advocacy and coaching.  The case manager will not provide treatment but will provide services that enhance the treatment process.  The goals of case management are to: (1) increase client retention in and completion of treatment in order to move clients toward recovery and independence and, (2) increase client access to core services such as primary health care, psychiatric care, and stable and secure living environments, positive support networks, education, vocational training and employment. These services are provided where the individual resides or needs services. The Caseload for staff is limited to 35 individuals.

Severity of Condition Criteria for Placement (County Specific for Populations Covered)

1. Admission to SUD Intensive Case Management is determined by The Single County Authority (SCA) or designee, with the individual’s consent. The following criteria must be met for referral to this service:

Adults, who have a substance use or addiction disorder and who meet  at least one of the following (the populations covered will be specific to each of the counties and there is a list attached to the end of this section with the county specific populations covered):

1. Pregnant Women
2. Women with Custody of Children under the age of 12
3. Persons with Severe Medical Conditions (i.e. HIV/AIDS, Tuberculosis)
4. IV Drug Users
5. Mentally ill substance abusers
6. High utilizers of services:
   1. Heavy users of detoxification services where other levels of SUD Treatment has been refused by the client. (Nine or more days within a six month period)
   2. Heavy utilizers of inpatient hospitalization services (Two or more in a twelve month period)

Intensity of Service and Continued Stay Criteria (Same for all counties)

All of the following criteria are necessary for continued care:

1. Demonstrates ability to comply with program requirements;
2. Demonstrates ability to benefit from this service;
3. There is progress toward the goals established in the service plan;
4. Continued inability to obtain or coordinate services without program support.

Psychosocial Factors

May be used as relevant to this level of care and as determined by the assessment.

Exclusion Criteria (Same for all Counties)

The individual chooses not to participate or is unable to participate in the program.

Discharge Criteria (Same for all counties)

The following criteria are sufficient for discharge from this level of care:

1. The individual no longer demonstrates need for the program as determined by the goals in the service plan.
2. The individual has had no contact with the case manager for a 30 day period.
3. The individual moves outside the service area of the case management unit and cannot be located.
4. The individual is in jail, pending disposition, or located in an institutional setting whereby case management services are either unnecessary or provided within that institutional setting.
5. The individual chooses to terminate services with the case management unit.
6. The individual is deceased.

Any individual presenting for substance use disorder services may receive an assessment / level of care determination. Assessment / Level of Care activities may include any or all of the following:

(1) Screening, (2) Assessment, (3) Level of Care Recommendation (based on ASAM), (4) Identification of need for referral to Intensive Case Management and (5) Arrangements for placement.

These services are provided by the Single County Authority (SCA) or may be contracted to other providers by the SCA.

Severity of Condition Criteria for Placement

1. Any individual presenting for substance use disorder services may receive any or all of the services identified below:
   1. Screening for the presence of Alcohol and Other Drug (AOD) Use and special needs
   2. Assessment of the degree, severity and impact on life areas of AOD
   3. Level of Care recommendation based on ASAM or other state approved
   4. Identification of need for referral to substance use disorder Intensive Case
   5. Facilitate placement for
2.  The individual is at risk or has a substance use or addiction

Intensity of Service and Continued Stay Criteria

Continued stay in a given level of care will be clinically determined by the client's needs as defined by ASAM Criteria or other state approved tool.

Psychosocial Factors

May be used as relevant to this level of care and as defined by the ASAM

Exclusion Criteria

Individual chooses not to participate or is unable to complete the assessment.

Discharge Criteria

1. Individual is place in recommended level of care or alternative level of care.
2. Individual elects not to follow-up with level of care
3. Individual's whereabouts become unknown.
4. Individual is incarcerated.

Intensive Case Management (ICM) is the organized approach to coordinating segments of a service delivery system in order to ensure the most comprehensive process for meeting an individual client’s needs for care.  Clients with complex, multiple problems will receive needed individualized services in a coordinated fashion at the time they are needed.  Case management provides evaluation of the client’s strengths and needs, service planning and goal setting, linking, implementing, monitoring, advocacy and coaching.  The case manager will not provide treatment but will provide services that enhance the treatment process.  The goals of case management are to: (1) increase client retention in and completion of treatment in order to move clients toward recovery and independence and, (2) increase client access to core services such as primary health care, psychiatric care, and stable and secure living environments, positive support networks, education, vocational training and employment. These services are provided where the individual resides or needs services.  The Caseload for staff is limited to 35 persons.

Severity of Condition Criteria for Placement (Each county will have their own Admission Criteria)

1. Admission to SUD Intensive Case Management is determined by the Single County Authority (SCA) or designee, with the individual’s consent. The following criteria must be met for referral to this service:
   1. Child/Adolescent who is at risk or has a substance use or addiction disorder and who meet at least one of the following:
   2. Pregnant Women (adolescents)
   3. Adolescents with Custody of Children under the age of 12
   4. Persons with Severe Medical Conditions (i.e. HIV/AIDS, Tuberculosis, Hepatitis and other liver diseases, seizure disorders, Diabetics requiring medication, Anorexia/Bulimia, Head Injuries)
   5. Student Assistance Program Referrals
   6. Multi-system child or adolescent
   7. High utilizers of services:
      1. Heavy users of detoxification services where other levels of SUD Treatment has been refused by the client. (Nine or more days within a six month period)
      2. Heavy utilizers of inpatient hospitalization services (Two or more in a twelve month period)
   8. IV Drug Users
   9. Mentally-ill substance abusers

Intensity of Service and Continued Stay Criteria (Same for all counties)

All of the following criteria are necessary for continued care:

1. Demonstrates ability to comply with program requirements;
2. Demonstrates ability to benefit from this service;
3. There is progress towards the goals established in the service plan;
4. Continued inability to obtain or coordinate services without program support.

Psychosocial Factors (Same for all counties)

These factors will be considered as determined by the ICM assessment.

Exclusion Criteria (Same for all counties)

The individual chooses not to participate or is unable to participate in the program.

Discharge Criteria (Same for all counties)

The following criterion is sufficient for discharge from this level of care:

1. Individual no longer demonstrates need for program as determined by the service plan.
2. Individual has had no contact with the case manager for a (30) day period.
3. Individual moves outside of the service area of the case management unit.
4. Individual is in jail, or some other institutional setting whereby case management services are either unnecessary or provided within that institutional setting.
5. Individual chooses to terminate services with the case management unit.
6. Individual is deceased.

This level of care provides 24-hour observation and supervision for individuals who do not require intensive clinical treatment in an inpatient psychiatric setting and would benefit from a short-term, structured stabilization setting that offers such services as crisis stabilization, evaluation, care management, medication management, and mobilization of family support and community resources.  This level of care may or may not be provided in a medical setting.  Some of the functions such as medication monitoring and physical care will require access to medical services. The other services do not necessarily require that they be provided by a physician or nurse and can be provided by other mental health professionals who are licensed and credentialed to provide the interventions listed, such as individual therapy, family therapy and crisis counseling.  This service is designed to facilitate the return of the individual to the community as rapidly as possible while generating the support necessary to maintain the optimum level of functioning. 

Procedures

Severity of Condition Criteria for Admission

To be eligible for this level of care, a psychiatric evaluation (conducted by a physician or individual working under the supervision of a physician who is within their scope of practice to complete a psychiatric evaluation) within 24 hours of the request) must reveal that the individual:

1. Does not have symptoms due solely to a substance use disorder;
2. Has active symptoms consistent with a DSM 5 or current DSM diagnosis that requires an intensive structured intervention;
3. Is experiencing dramatic and sudden decompensation, with a strong potential for danger to self and/or others, and has no available family/significant supports to provide continuous monitoring;
4. Can be effectively treated with short-term intensive stabilization services and returned to a less intensive level of care within a brief time frame; and
5. Is experiencing the onset of a life-endangering psychiatric condition, but there is insufficient information to determine the appropriate level of care.

Intensity of Service and Continued Stay Criteria

All of the following criteria are necessary for continued treatment at this level of care:

1. All crisis stabilization services including but not limited to, assessment,/evaluation, medication monitoring as indicated, individual/grp, discharge planning,   is rendered in a clinically appropriate manner and is focused on the outcomes defined in the discharge/transition plan; as well as on current symptomology that lead to admission.
2. Treatment planning is individualized, realistic, and appropriate to the individual’s condition and symptoms presented upon assessment, with specific goals and objectives stated, focusing on short term intervention.
3. All crisis services are available  24/7 and treatment interventions conducted daily are carefully structured to achieve maximum results (e.g., self-sufficiency) and demonstrate progress in stabilizing current crisis/symptoms  in the most timely way possible;
4. Condition continues to meet admission criteria at this level of care and a less intensive level of care would be inadequate;
5. Documented evidence of concerted efforts crisis and safety planning, identifying community supports, securing appropriate follow up services  to establish a realistic discharge plan to transition the individual to a less intensive level of care; and
6. Individual demonstrates the ability to derive a benefit from the evaluation and treatment services provided within the program.

Psychosocial Factors

Factors such as family dynamics, support system, financial and social need, homelessness, abuse/neglect, current or past trauma, unemployment or other social determinants of health may change the risk assessment and should be considered when making level of care placement decisions.

Exclusion Criteria

Any of the following criteria are sufficient for exclusion from this level of care:

1. Condition is such that it can only be safely treated in an acute inpatient setting;
2. Sole need is permanent/temporary placement for housing, food, clothing or other social needs.

Discharge Criteria

Any of the following criteria are sufficient for discharge from this level of care:

1. Treatment plan goals and objectives have been substantially met;
2. No longer meets admission criteria or meets criteria for a less/more intensive level of care;
3. Individual is actively noncompliant in treatment or in following program rules and regulations; or
4. Alternative support systems that enable the individual to be maintained in a less restrictive treatment environment have been secured.

Acute partial hospitalization is a nonresidential treatment program that may or may not be hospital-based.  The program provides clinical diagnostic and treatment services on a level of intensity equal to an inpatient program, but on less than a 24-hour basis. These services may include therapeutic milieu, nursing, psychiatric evaluation and medication management, group and individual/family therapy, psychological testing, vocational counseling, rehabilitation recovery counseling, substance use assessment and referral and treatment plans.

The environment at this level of treatment is highly structured, and there should be a staff-to-patient ratio sufficient to ensure necessary therapeutic services, professional monitoring, and protection.  The partial staff ratio should follow minimum standards set forth in Pennsylvania state regulations Title 55. Chapter 5210 Partial Hospitalization that are 1FTE clinical staff member to every 6 patients. Acute psychiatric partial hospital treatment may be appropriate when a patient does not require the more restrictive and intensive environment of a 24-hour inpatient setting but does need four to six hours of clinical services per day with the expectation that services are provided up to five days per week.  Acute partial hospitalization is used as a time-limited response to stabilize acute symptoms. As such, it can be used both as a transitional level of care (i.e., step-down from inpatient) as well as a stand-alone level of care to stabilize a deteriorating condition and avert hospitalization. Beacon PA certification guidelines (Policy CN.23) indicates precertification up to 10 days and a continued stay up to 5 days

Treatment efforts need to focus on the individual's response during treatment program hours, as well as the continuity and transfer of treatment gains during the individual's non-program hours in the home/community.  Comprehensive treatment planning is individualized and appropriate to the individual’s changing condition with realistic and specific goals and objectives stated.  Treatment planning should include active family or other support systems, social, occupational and interpersonal assessment with involvement when indicated. 

Acute psychiatric partial hospital treatment is separate and distinct from non-acute partial hospitalization program (see CL.4.304) based on the level of intensity of the services as indicated by length of stay, number of days of attendance per week, individual program description and Beacon PA certification guidelines (Policy CN.23).  In addition, acute psychiatric partial hospital treatment is separate and distinct from psychiatric and social rehabilitation programs or day treatment programs.  Non acute partial hospitalization programs and/or day treatment programs and/or social rehabilitation programs are usually less psychiatrically-based, located in a community setting, and focus more on the development, enhancement and maximization of an individual’s level of functioning (e.g. self-sufficiency, communication skills and social support network) necessary for daily social and occupational functioning.

Criteria

Admission Criteria

All of the following criteria are necessary for admission:

1. The individual is age 18 and older and is experiencing an acute episode of a DSM 5 or current DSM Disorder and would face imminent risk of inpatient hospitalization without intensive treatment.
2. There is evidence of the individual’s capacity and support for reliable attendance at the acute partial hospitalization program.
3. There is an adequate social support system available to provide the stability necessary for maintenance in the program OR the individual demonstrates the capacity to assume responsibility for his/her own safety outside program hours.
4. The individual’s risk to self, others, or property (e.g. inability to undertake self-care; mood, thought or behavioral disorder interfering significantly with activities of daily living; suicidal ideation or non-intentional threats or gestures; risk-taking or other self-endangering behavior) is not so serious as to require 24-hour medical/nursing supervision and needs cannot be met at a lower level of care. The individual does require structure and supervision for a significant portion of the day and family/community support when away from the acute partial hospitalization program.
5. The individual’s condition requires a comprehensive, multi-disciplinary, multi-modal course of treatment, including routine medical observation/supervision to effect significant regulation of medication and/or routine nursing observation and behavioral intervention to maximize functioning and minimize risks to self, others and property.

Psychosocial, Occupational, and Cultural and Language Factors

These factors may change the risk assessment and should be considered when making level of care decisions and reflected in the treatment planning process.

Exclusion Criteria

Any of the following criteria are sufficient for exclusion from this level of care:

1. The individual is an active or potential danger to self or others or sufficient impairment exists that a more intense level of service is required.
2. The individual does not voluntarily consent to admission or treatment and is not involuntarily committed to this level of care.
3. The individual has medical conditions that would prevent beneficial utilization of services and appropriate accommodations cannot be made.
4. The individual can be safely maintained and effectively treated at a less intensive level of care.
5. The primary problem is social, economic (i.e. housing, family conflict, etc.), legal or one of physical health without a concurrent major psychiatric episode meeting criteria for this level of care.
6. The focus of treatment is primarily for peer socialization and group support. 

Continued Stay Criteria

All of the following criteria are necessary for continuing treatment at this level of care:

1. The individual’s condition continues to meet admission criteria at this level of care.
2. The individual’s treatment does not require a more intensive level of care, and no less intensive level of care would be appropriate.
3. The individual demonstrates a current or historical inability to sustain/maintain gains without a comprehensive program of treatment services.
4. Progress in relation to specific symptoms or impairments is clearly evident and can be described in objective terms, but goals of treatment have not yet been achieved. If there is lack of progress, appropriate adjustments in the treatment plan are documented.
5. The individual is an active participant in treatment and discharge planning.

Discharge Criteria

The following criteria are sufficient for discharge from this level of care:

1. There is a discharge plan with follow-up appointments in place prior to discharge.
   
   And any of the following
   
   
2. The individual’s documented treatment plan, goals and objectives have been substantially met.
3. The individual no longer meets the admission criteria or meets criteria for a less or more intensive level of care.
4. Consent for treatment is withdrawn.
5. The individual is not making progress toward treatment goals and there is no reasonable expectation of progress at this level of care despite documented treatment planning changes and a recommendation is made for another level of care.

This level of care provides 24-hour observation, supervision, and support for children/adolescents who do not require intensive clinical treatment in an inpatient psychiatric setting. The child/adolescent would benefit from a short-term, structured stabilization/respite setting that offers such services as crisis stabilization, evaluation, care management, medication management, and mobilization of family support and community resources. The service is designed to facilitate the return of the child/adolescent to the community as rapidly as possible while generating the support necessary to maintain the optimum level of functioning

Procedures

Severity of Condition Criteria for Admission

All of the following are necessary for admission to this level of care:

1. Individual demonstrates symptoms consistent with a DSM 5 or current DSM diagnosis that requires an intensive structured intervention;
2. Clinical evaluation indicates an increase in symptoms to the extent that there is a strong potential for danger to self and/or others, and individual has insufficient family/guardian or other community supports to provide continuous monitoring;
3. Clinical evaluation indicates that the individual can be effectively treated with short-term intensive stabilization services and returned to a less intensive level of care within a brief time frame; and

Intensity of Service and Continued Stay Criteria

All of the following criteria are necessary for continued treatment at this level of care:

1. All crisis stabilization services including but not limited to, assessment,/evaluation, medication monitoring as indicated, individual/group, discharge planning, is rendered in a clinically appropriate manner and is focused on the outcomes defined in the discharge/transition plan, as well as on current symptomology that lead to admission.
2. Treatment planning is individualized, realistic, and appropriate to the individual’s condition and symptoms presented upon assessment, with specific goals and objectives stated, focusing on short term intervention.
3. All crisis services are available  24/7 and treatment interventions conducted daily are carefully structured to achieve maximum results (e.g., self-sufficiency) and demonstrate progress in stabilizing current crisis/symptoms in the most timely way possible;
4. Condition continues to meet admission criteria at this level of care and a less intensive level of care would be inadequate;
5. Documented evidence of concerted efforts crisis and safety planning, identifying community supports, securing appropriate follow up services  to establish a realistic discharge plan to transition the individual to a less intensive level of care; and
6. Individual demonstrates the ability to derive a benefit from the evaluation and treatment services provided within the program.

Psychosocial Factors

Factors such as family dynamics, support system, financial and social need, homelessness, abuse/neglect, current or past trauma, unemployment or other social determinants of health may change the risk assessment and should be considered when making level of care placement decisions.

Exclusion Criteria

Any of the following criteria are sufficient for exclusion from this level of care:

1. Psychiatric condition is of such severity that it can only be safely treated in an inpatient setting;
2. Condition is such that it cannot be safely treated in any setting other than that of a medical facility; or
3. Sole need is permanent/temporary placement.

Discharge Criteria

Any of the following criteria are sufficient for discharge from this level of care:

1. Treatment plan goals and objectives have been substantially met;
2. Child/adolescent no longer meets admission criteria or continued stay criteria, or meets criteria for a less/more intensive level of care;
3. Child/adolescent is non-participatory in treatment despite attempts to engage or in following program rules and regulations; or
4. Alternative support systems that enable the child/adolescent to be maintained in a less intensive treatment environment have been secured.

Acute partial hospitalization is a nonresidential treatment program that may or may not be hospital-based.  The program provides clinical diagnostic and treatment services on a level of intensity equal to an inpatient program, but on less than a 24-hour basis.  These services may include therapeutic milieu, nursing, psychiatric evaluation and medication management, group and individual/family therapy, psychological testing, prevocational counseling, academic, substance use education, prevention, assessment, referral and treatment planning.

The environment within this level of care is highly structured, and as such, there should be a staff-to-patient ratio sufficient to ensure necessary therapeutic services, professional monitoring, and patient .safety. The partial staff ratio should follow minimum standards set forth in Pennsylvania state regulations Title 55. Chapter 5210 Partial Hospitalization section 5210.31 that are 1 FTE for every 5 patients. Acute psychiatric partial hospital treatment may be appropriate when a patient does not require the more restrictive and intensive environment of a 24-hour inpatient setting, but does need four to six hours of clinical services per day with the expectation that services are provided  five days per week.  Acute partial hospitalization is used as a time-limited response to stabilize acute symptoms.  As such, it can be used both as a transitional level of care (i.e., step-down from inpatient) as well as a stand-alone level of care to stabilize a deteriorating condition and avert hospitalization. Beacon Pa certification guidelines (Policy CN.23) indicates precertification up to 10 days and a continued stay up to 5 days.  Treatment efforts need to focus on the individual’s response during treatment program hours, as well as the continuity and transfer of treatment gains during the individual’s non-program hours in the home/school/community.  Comprehensive treatment planning is individualized and appropriate to the individual’s changing condition with realistic and specific goals and objectives stated.  Treatment planning should include active family or other support systems, social, educational and interpersonal assessment with involvement when indicated.

Acute psychiatric partial hospital treatment is separate and distinct from non-acute partial hospitalization program based on the level of intensity of the services (see CL.6.402) as indicated by length of stay, number of days of attendance per week, individual program description and Beacon Pa certification guidelines (Policy CN.23).  In addition, acute psychiatric partial hospital treatment is separate and distinct from school-based programs or day treatment programs.  School-based programs, Non –acute partial hospitalization and/or day treatment  are usually less psychiatrically-based, located in a community setting, and focus more on the development or enhancement of an individual’s coping skills necessary for daily social and academic functioning as well as focusing on maximization of an individual’s level of functioning (e.g. self-sufficiency, communication skills and social support network

Criteria

Admission Criteria

All of the following criteria are necessary for admission:

1. The individual is age 17 or under OR If between the ages of 18-21, either of the following must apply:
   
   
   • Is enrolled as a Full-Time student in High School, Secondary Education and/or Vocational Technical Training
   • Is in the custody of Children and Youth Services
2. The individual demonstrates symptomatology consistent with a DSM 5 or current DSM (IDD or SUD cannot stand alone) diagnosis by a psychiatrist or psychologist that requires and can reasonably be expected to respond to therapeutic intervention.
3. Acute partial hospitalization must be recommended as the most clinically appropriate and least restrictive service available for the child by the treatment team which shall include the child, parent/guardian and/or caretaker and case manager.
4. There is evidence of the individual’s capacity and support for reliable attendance at the acute partial hospitalization program.
5. There is an adequate social support system available to provide the stability necessary for maintenance in the program.
6. The individual’s risk to self, others, or property (e.g., inability to undertake self-care; mood, thought or behavioral disorder interfering significantly with activities of daily living; suicidal ideation or non-intentional threats or gestures; risk-taking or other self-endangering behavior) is not so serious as to require 24-hour medical/nursing supervision, and treatment needs cannot be met at a lower level of care. The individual does require structure and supervision for a significant portion of the day and family/community support when away from the acute partial hospitalization program.
7. The individual’s condition requires a comprehensive, multi-disciplinary, multi-modal course of treatment.  This includes routine medical observation/supervision to effect significant regulation of medication and/or routine nursing observation and behavioral intervention to maximize functioning and minimize risk to self, others and property.

Psychosocial, Academic, Cultural and Language Factors

These factors may change the risk assessment and should be considered when making level of care decisions and reflected in the treatment planning process.

Exclusion Criteria

Any of the following criteria are sufficient for exclusion from this level of care:

1. The individual is an active or potential danger to self or others or sufficient impairment exists that a more intense level of service is required.
2. The individual or legal guardian does not voluntarily consent to admission or treatment and is not involuntarily committed to this level of care.
3. The individual has medical conditions or impairments that would prevent beneficial utilization of services.
4. The individual can be safely maintained and effectively treated at a less intensive level of care.
5. The primary problem is social, academic, legal or one of physical health without a concurrent major psychiatric episode meeting criteria for this level of care.
6. The focus of treatment is primarily for peer socialization and group support.

Continued Stay Criteria

All of the following criteria are necessary for continuing treatment at this level of care:

1. The individual’s condition continues to meet admission criteria at this level of care;
2. The individual’s treatment does not require a more intensive level of care, and no less intensive level of care would be appropriate.
3. The individual demonstrates a current or historical inability to sustain/maintain gains without a comprehensive program of treatment services.
4. Progress in relation to specific symptoms or impairments is clearly evident and can be described in objective terms, but goals of treatment have not yet been achieved. If there is lack of progress, appropriate adjustments in the treatment plan are documented.
5. The individual, parent/guardian and/or caretaker are active participants in treatment and discharge planning.

***If the individual does not meet these criteria for continued stay then alternative treatments/programs will be sought that will meet the needs of the individual.

Discharge Criteria

The following criteria are sufficient for discharge from this level of care:

There is a discharge plan with follow-up appointments in place prior to discharge.

And any of the following

1. The individual’s documented treatment plan, goals and objectives have been substantially met.
2. The individual no longer meets the admission criteria, or meets criteria for a less or more intensive level of care.
3. Consent for treatment is withdrawn.
4. The individual is not making progress toward treatment goals and there is no reasonable expectation of progress at this level of care despite documented treatment planning changes.

Multi-systemic Therapy (MST) is an intensive family and community-based treatment that addresses the multiple determinants of serious antisocial behavior. MST is provided using a home-based model of services delivery targeting adolescents ages 12-17, at high risk of out-of-home placement and exhibiting antisocial, violent or illegal behaviors or substance abuse issues, and their families. MST interventions typically aim to improve caregiver discipline practices, enhance family affective relations, increase youth ability to avoid negative peer interactions, increase youth association with prosocial peers, improve youth school or vocational performance, engage youth in prosocial recreational outlets, and develop an indigenous support network of extended family, neighbors, and friends to help caregivers achieve and maintain such changes. Services are typically delivered from 20-40 hours per month, over the course of 20 weeks (140 days) with the possibility of an extension of up to 40 additional days, and include on-call crisis availability 24/7.

Criteria

Admission Criteria

All of the first three criteria are necessary for admission, in addition to any one of criteria 4-10:

       All of the following three:

1. The individual has a diagnosis from the most recent version of the Diagnostic and Statistical Manual (DSM) characterized by externalizing behaviors such as Conduct Disorder, Intermittent Explosive Disorder, ADHD and Oppositional Defiant Disorder. Other mental health disorders may be appropriate in conjunction with externalizing behaviors mentioned above which require and can reasonably be expected to respond to therapeutic intervention. The diagnoses of ID or SUD cannot stand alone. In addition, the individual is between the ages of 12-17 but children or adolescents falling outside this age range may be assessed on an individualized basis for appropriateness of treatment.
2. The individual has a behavioral problem of such severity that functioning in his/her home or community requires specialized intervention.
3. The individual is able to remain in his/her home and has at least one caregiver willing to actively participate in the treatment. The individual’s caregiver is not able to adequately manage the individual’s behavioral problems and needs to learn new behavioral management techniques.

Any one or more of the following:

4. The individual is adjudicated and on probation, or returning home from out-of-home care.
5. The individual is at risk for out-of-home placement.
6. The individual could benefit from ASAM Level 0.5 Early Intervention services. ASAM Level of Care with more intensity than Level 0.5 is not exclusionary, but would be addressed by referral to a licensed DDAP provider for assessment and intervention.
7. There is a history of previous unsuccessful interventions.
8. The individual is a repeat or violent juvenile offender.
9. The individual has experienced a recent crisis or high family conflict.
10. There is ongoing multiple system involvement (e.g.., school, mental health, drug and alcohol, JPO, CYS, etc.).

Exclusion Criteria

Any of the following criteria are sufficient for exclusion from this level of care:

1. The individual presents too high a risk for danger to self and/or others or sufficient impairment exists that a more intensive level of service is required.
2. The individual is exhibiting active psychotic symptoms at the time of referral.
3. The individual is living independently, or a caregiver cannot be identified to provide support and involvement in treatment.
4. The individual has sexual offending behaviors in the absence of other anti-social behaviors.
5. The individual needs an ASAM Level of Care with more intensity than ASAM Level 0.5 is not exclusionary, but would be addressed by referral to a licensed DDAP provider for assessment and intervention.

Continuing Stay Criteria

All of the following criteria are necessary for continuing treatment at this level of care:

1. The individual's condition continues to meet admission criteria at this level of care.
2. The individual's treatment does not require a more intensive level of care, and no less intensive level of care would be appropriate.
3. Treatment plan has been updated with recommendation for continuation and adjusted to revise expectations for outcomes based on the need for continued treatment. Treatment planning is individualized and appropriate to the individual’s changing condition with realistic and specific goals and objectives stated. The treatment plan has been developed, implemented and updated, based on the individual’s clinical condition and response to treatment, as well as the strengths of the family. Treatment planning should include active family or other support systems involvement, as appropriate and/or feasible, and comprehensive assessment of family functioning.
4. An individualized discharge plan has been updated, which includes the revised, specific realistic, objective and measurable discharge criteria and plans for appropriate follow-up care.
5. Progress in relation to specific symptoms or impairments is clearly evident and can be described in objective terms, but goals of treatment have not yet been achieved and adjustments in the treatment plan to address lack of progress are evident. 

OR

Goals of treatment have been met but individual/caregiver has not demonstrated 4-6 weeks of independent functioning indicating that gains in treatment goals can be maintained (sustainability).        

1. The individual is actively involved in treatment, or there are active, persistent efforts being made that can reasonably be expected to lead to the individual’s engagement in treatment.
2. There is a documented active attempt at coordination of care with relevant providers and support systems when appropriate.

Discharge Criteria

Any of the following must be met for discharge from this level of care:  

1. The individual's documented treatment plan goals and objectives have been substantially met.
2. The individual no longer meets admission criteria or meets criteria for a less or more intensive level of care.
3. The individual and/or caregiver has not benefited from MST despite documented efforts to engage the individual and/or caregiver and there is no reasonable expectation of progress at this level of care despite treatment planning changes.

AND

An individualized discharge plan with appropriate, realistic and timely follow-up care is in place.

Multi-systemic Therapy-Psychiatric Care (MST-Psych) is an intensive family and community-based treatment that addresses the multiple determinants of serious antisocial behavior. MST is provided using a home-based model of services delivery targeting children and youth ages 9-17. MST-Psych primarily targets youth at risk for out of home placement or psychiatric hospitalization due to serious behavioral problems and co-occurring mental health symptoms. MST-Psych is designed to help the child, youth avoid placement in juvenile justice and/or residential treatment facilities and can be used to treat children, youths and families that are excluded from treatment on standard MST due to the severity of the child, youth and parent/caregiver’s mental health symptoms. MST-Psych addresses safety risks associated with suicidal, homicidal, or psychotic behavior. MST-Psych utilizes evidence-based assessment and treatment of child, youth and parent/caregiver mental illness. MST interventions typically aim to improve caregiver discipline practices, enhance family affective relations, increase youth ability to avoid negative peer interactions, increase youth association with prosocial peers, improve youth school or vocational performance, engage youth in prosocial recreational outlets, and develop an indigenous support network of extended family, neighbors, and friends to help caregivers achieve and maintain such changes. MST-Psych is different from traditional MST because of the incorporation of psychiatrists and crisis caseworkers into the team, as well as additional respite placement resources, and substantial additions to the training, supervision and quality assurance protocols. Services are typically delivered from 20-40 hours per month, over the course of 180 days, with the possibility of extension for up to 30 additional days as needed and include on-call crisis availability 24/7.

Criteria

Admission Criteria

All of the first four criteria are necessary for admission, in addition to any one of criteria 5-11:

All of the following four:

1. The individual is between the ages of 9-17, but children or adolescents falling outside this age range may be assessed on an individualized basis for appropriateness of treatment.
2. The individual has a diagnosis from the most recent version of the Diagnostic and Statistical Manual (DSM) such as thought disorder, bipolar affective disorder, depression, anxiety, and substance use/disorder and exhibits acting out behaviors such as physical and verbal aggression, truancy, problematic school behavior and performance issues, curfew violations, substance use, and criminal behaviors. Other mental health disorders may be appropriate for MST-Psych, but only when they occur in conjunction with internalizing behaviors mentioned above which require and can reasonably be expected to respond to therapeutic intervention. The diagnoses of ID or SUD cannot stand alone.
3. The severity of the individual’s behavioral problems is such that functioning in the home or community requires specialized intervention.
4. The individual is able to remain in their home and has at least one caregiver willing to actively participate in the treatment. The individual’s caregiver is not able to adequately manage the individual’s behavioral problems and needs to learn new behavioral management techniques.

Any one or more of the following:

5. The individual is adjudicated and on probation, or returning home from out-of-home care.
6. The individual is at risk for out-of-home placement.
7. The individual could benefit from ASAM Level 0.5 Early Intervention services. ASAM Level of Care with more intensity than Level 0.5 is not exclusionary, but would be addressed by referral to a licensed DDAP provider for assessment and intervention.
8. There is a history of previous unsuccessful interventions.
9. The individual is a repeat or violent juvenile offender.
10. The individual has experienced a recent crisis or high family conflict.
11. There is ongoing multiple system involvement (e.g.., school, mental health, substance use, JPO, CYS, etc.).

Exclusion Criteria

All of the following criteria are necessary for continuing treatment at this level of care:

1. The individual's condition continues to meet admission criteria at this level of care.
2. The individual's treatment does not require a more intensive level of care, and no less intensive level of care would be appropriate.
3. Treatment plan has been updated with recommendation for continuation and adjusted to revise expectations for outcomes based on the need for continued treatment. Treatment planning is individualized and appropriate to the individual’s changing condition with realistic and specific goals and objectives stated. The treatment plan has been developed, implemented and updated, based on the individual’s clinical condition and response to treatment, as well as the strengths of the family. Treatment planning should include active family or other support systems involvement, as appropriate and/or feasible, and comprehensive assessment of family functioning.
4. An individualized discharge plan has been updated which includes the revised, specific, realistic, objective and measurable discharge criteria and plans for appropriate follow-up care.
5. Progress in relation to specific symptoms or impairments is clearly evident and can be described in objective terms, but goals of treatment have not yet been achieved and adjustments in the treatment plan to address lack of progress are evident. 

OR

Goals of treatment have been met but individual/caregiver has not demonstrated 3-4 weeks of independent functioning indicating that gains in treatment goals can be maintained (sustainability).

1. The individual is actively involved in treatment, or there are active, persistent efforts being made that can reasonably be expected to lead to the individual’s engagement in treatment.
2. There is a documented active attempt at coordination of care with relevant providers and support systems when appropriate.

Discharge Criteria

Any of the following must be met for discharge from this level of care:  

1. The individual's documented treatment plan goals and objectives have been substantially met.
2. The individual no longer meets admission criteria or meets criteria for a less or more intensive level of care.
3. The individual and/or caregiver has not benefited from MST-Psych despite documented efforts to engage the individual and/or caregiver and there is no reasonable expectation of progress at this level of care despite treatment planning changes.

AND

An individualized discharge plan with appropriate, realistic and timely follow-up care is in place.

MST-PSB is an evidenced-based, intensive family and community-based treatment model for youth, ages 10-17, exhibiting problem sexual behavior and other high-risk behaviors, at home, at school and in the community. MST-PSB targets youth exhibiting sexually-related antisocial or delinquent behaviors and/or are at risk for out of home placement and/or are involved with the child welfare, juvenile justice or any other system due to problem sexual behaviors.  These problem sexual behaviors can occur with or without other externalizing, delinquent behaviors.  Therefore, youth whose primary presenting issue is problem sexual behavior will be appropriate for MST-PSB, whereas those same youth would not be appropriate for ‘Standard’ MST services. 

The program addresses the multiple systems and factors that affect the youth’s behavior and focuses on improving the overall function of the family to maintain youth safely in the community. MST-PSB is designed to help youth avoid placement in juvenile justice and/ or residential treatment facilities and also supports youth returning to the community from incarceration or residential placement. MST-PSB empowers caregivers to effectively parent their children and includes a strong focus on youth’s grooming behaviors (when present), family and youth characteristics related to sexual offense, community/physical environment and history of sexually abusive behaviors.  MST-PSB addresses any actual and potential victims’ physical, emotional and psychological safety. MST-PSB requires caregiver commitment to enforcing strategies and intervention plans. Services are typically delivered from 20-40 hours per month, over the course of 180 days with the possibility of an extension of up to 30 additional days, and include on-call crisis availability 24/7.

Criteria

Admission Criteria

All of the first three criteria are necessary for admission, in addition to any one of criteria 4-11:

All of the following three:

1. The individual has a diagnosis from the most recent version of the Diagnostic and Statistical Manual (DSM) characterized by externalizing behaviors such as Conduct Disorder, Intermittent Explosive Disorder, ADHD and Oppositional Defiant Disorder. Other mental health disorders may be appropriate for MST but only when they occur in conjunction with the externalizing behaviors mentioned above, which require, and can reasonably be expected to respond to, therapeutic intervention. The diagnoses of ID or SUD cannot stand alone. In addition, the individual is between the ages of 10-17, but children or adolescents falling outside this age range may be assessed on an individualized basis for the appropriateness of treatment.
2. The individual has a behavioral problem of such severity that functioning in his/her home or community requires specialized intervention.
3. The individual is able to remain in his/her home and has at least one caregiver willing to actively participate in the treatment. The individual’s caregiver is not able to adequately manage the individual’s behavioral problems and needs to learn new behavioral management techniques.

Any one or more of the following:

4. Youth who have engaged in problem sexual behaviors with siblings, other youthful family members, extended family, and/or peers and who have not been involved in the judicial system.
5. The individual is adjudicated and on probation or returning home following a residential placement, detention, group, or foster care.
6. Youth who risk of out-of-home placement due to sexually related antisocial or delinquent behaviors, and/or involved with the juvenile justice or child welfare systems due to problem sexual behaviors.
7. The individual could benefit from ASAM Level 0.5 Early Intervention services. ASAM Level of Care with more intensity than Level 0.5 is not exclusionary, but would be addressed by referral to a licensed DDAP provider for assessment and intervention.
8. There is a history of previous unsuccessful interventions.
9. The individual is a repeat or violent juvenile offender.
10. The individual has experienced a recent crisis or high family conflict.
11. There is ongoing multiple system involvement (e.g.., school, mental health, drug and alcohol, JPO, CYS, etc.).

Exclusion Criteria

Any of the following criteria are sufficient for exclusion from this level of care:

1. The individual presents too high a risk for danger to self and/or others or sufficient impairment exists that a more intensive level of service is required.
2. The youth is in need of crisis stabilization due to active suicidal, homicidal, or psychotic behavior (once sufficiently stabilized, youth who meet inclusionary criteria may be referred to the MST-PSB program).
3. The individual is living independently, or a caregiver cannot be identified to provide support and involvement in treatment.
4. The youth is on the Autism Spectrum Disorder (occasionally clinical exceptions are made for youth who are only mildly impaired).
5. The individual needs an ASAM Level of Care with more intensity than ASAM Level 0.5 is not exclusionary, but would be addressed by referral to a licensed DDAP provider for assessment and intervention.

Continuing Stay Criteria

All of the following criteria are necessary for continuing treatment at this level of care:

1. The individual's condition continues to meet admission criteria at this level of care.
2. The individual's treatment does not require a more intensive level of care, and no less intensive level of care would be appropriate.
3. Treatment plan has been updated with recommendation for continuation and adjusted to revise expectations for outcomes based on the need for continued treatment. Treatment planning is individualized and appropriate to the individual’s changing condition with realistic and specific goals and objectives stated. The treatment plan has been developed, implemented and updated, based on the individual’s clinical condition and response to treatment, as well as the strengths of the family. Treatment planning should include active family or other support systems involvement, as appropriate and/or feasible, and comprehensive assessment of family functioning.
4. An individualized discharge plan has been updated which includes the revised, specific, realistic, objective and measurable discharge criteria and plans for appropriate follow-up care.
5. Progress in relation to specific symptoms or impairments is clearly evident and can be described in objective terms, but goals of treatment have not yet been achieved and adjustments in the treatment plan to address lack of progress are evident. 

OR

Goals of treatment have been met but individual/caregiver has not demonstrated 4-6 weeks of independent functioning indicating that gains in treatment goals can be maintained (sustainability).  

1. The individual is actively involved in treatment, or there are active, persistent efforts being made that can reasonably be expected to lead to the individual’s engagement in treatment.
2. There is a documented active attempt at coordination of care with relevant providers and support systems when appropriate.

Discharge Criteria

Any of the following must be met for discharge from this level of care:  

1. The individual's documented treatment plan goals and objectives have been substantially met.
2. The individual no longer meets admission criteria or meets criteria for a less or more intensive level of care.
3. The individual and/or caregiver has not benefited from MST-PSB despite documented efforts to engage the individual and/or caregiver and there is no reasonable expectation of progress at this level of care despite treatment planning changes.

AND

An individualized discharge plan with appropriate, realistic and timely follow-up care is in place.

Treatment Resistant Depression Program: Electroconvulsive Therapy (ECT). Esketamine. and Transcranial Magnetic Stimulation (TMS)

Electro-convulsive Therapy (ECT):

1. Initiation of ECT: All of the following criteria a and b, and cord must be met:
   1. DSM or corresponding ICD diagnosis of major depression, schizophrenia, schizoaffective mood disorder, or other disorder with features that include mania, psychosis, and/or catatonia;
   2. Member has been medically cleared and there are no contraindications to ECT (i.e. lntracranial or cardiovascular, or pulmonary contraindications);
   3. There is immediate need for rapid, definitive response due to at least one of the following:
      1. Significant risk of harm to self or others;
      2. Catatonia;
      3. Intractable manic episode;
      4. Other treatment could potentially harm the member due to slower onset of action
   4. The benefits of ECT outweigh the risks of other treatments as evidenced by at least one of the following:
      1. Member has not responded to adequate medication trials;
      2. Member has had a history of positive response to ECT
2. Maintenance ECT: as indicated by all of the following:
   1. Without maintenance ECT member is at risk for relapse
   2. Adjunct therapy to pharmacotherapy

Transcranial Magnetic Stimulation (TMS):

1. Transcranial magnetic stimulation may be indicated when ALL of the following are present:
   1. Age 18 years or older
   2. Treatment resistant major depressive disorder and 1 more of the following:
      1. Inadequate response to pharmacotherapy despite all of the following:
         1. Adequate duration and dosage
         2. Documented adherence
         3. Trials from 2 or more classes of medications
      2. Inability to tolerate pharmacotherapy as evidenced by 2 trials of agents with documented side effects
2. Continuation of TMS, up to 6 months, as indicated by all of the following:
   1. Continuation of symptoms after acute treatment phase
   2. Previous positive response to acute treatment
3. TMS Exclusionary Criteria:
   1. Acute or chronic psychotic symptoms or disorders (i.e. schizophrenia, schizophreniform, or schizoaffective disorder)
   2. Cochlear implant, deep brain stimulator, or vagus nerve stimulator
   3. Current use of substances that maysignificantly lower seizure threshold (i.e. alcohol, stimulants)
   4. Epilepsy or history of seizure or presence of other neurologic disease that may lower seizure threshold (i.e. cerebrovascular accident, severe head trauma, increased intracranial pressure)
   5. Metallic hardware or implanted magnetic-sensitive medical device (i.e. implanted cardioverter-defibrillator, pacemaker, metal aneurysm clips or coils) at a distance within the electromagnetic field of the discharging coil (i.e. less than or equal to 30 cm to the discharging coil)

Esketamine Therapy:

1. The answers to ALL of the following must be fulfilled in order to meet medical necessity criteria:
   1. All SPRAVATO Risk Evaluation and Mitigation Strategy requirements have been met https://www.spravatorems.com/
   2. Adults <65 years of age with current diagnosis of unipolar major depressive disorder by DSM-5
   3. The individual did not achieve remission from at least four adequate trials (dose and duration) of antidepressants, either alone or in combination with evidence-based psychotherapy, and in the current episode of depression is experiencing moderate to severe depressive symptomology based on a depression rating scale within the last 30 At least two trials must include an antidepressant augmented with an additional agent (i.e. antipsychotic, second antidepressant, lithium, or thyroid supplementation) OR the patient is hospitalized with MDD complicated by acute suicidal ideation or behavior. Antidepressant treatment trials are considered unsuccessful if the patient has not responded to at least 6 weeks of antidepressant at half maximum dose or greater.
   4. The patient has been considered for Electro-convulsive therapy (ECT)
   5. The patient has started and is currently receiving a new antidepressant that has not previously failed in the current depressive episode
   6. The prescriber is a psychiatrist or a licensed health-care provider (i.e. CPP, NP, PA)
   7. The patient agrees to stay and be monitored for at least 2 hours after esketamine administration and agrees not to drive or operate heavy machinery/equipment and not to make major financial or legal decisions for the remainder of the day in which the esketamine is administered
   8. The patient or their legal representative can provide signed informed consent
   9. The patient has an adult who can accompany him/her and assist with transportation, or another method of safe transport has been arranged and documentd
   10. For women of childbearing potential: pregnancy should be excluded prior to receiving esketamine and the patient provided contraceptive counseling on potential risks benefits of taking esketamine if patient were to become pregnant
2. Esketamine Exclusionary Criteria: if the answer to any of the below is met, then the patient should NOT receive esketamine
   1. Hypersensitivity to esketamine, ketamine, or any of the excipients
   2. Aneurysmal vascular disease (including thoracic and abdominal aorta, intracranial, and peripheral arterial vessels) or arteriovenous malformation
   3. History of intracerebral hemorrhage
   4. History of seizures
   5. Current or recent (within 30 days) delirium
   6. Current uncontrolled hypertension (systolic blood pressure >140mm Hg or diatolic blood pressure >90mm Hg)
   7. Severe cardiac decompensation (class IV heart failure or unstable angina)
   8. Severe hepatic impairment (Child-Pugh class C)
   9. Current or previous interstitial or ulcerative cystitis
   10. Comorbid psychiatric condition is present (schizophrenia, schizoaffective disorder, MDD with psychotic features, bipolar disorder, obsessive-compulsive disorder, intellectual disability, autism, cluster B personality disorder, or a major neurocognitive disorder diagnosis)
   11. History of non-response to ketamine, esketamine, or ECT
   12. History of Vagal Nerve Stimulation or deep brain stimulation in current episode of depression
   13. Current or previous abuse of ketamine or esketamine
   14. Clinical evidence for current substance abuse except tobacco use (i.e. confirmed UDS)
   15. Current barbiturate, cannabis, or opioid use
   16. Current moderate or severe substance use disorder (SUD)
   17. Pregnancy (known pregnancy or positive pregnancy test)
   18. Patient is breastfeeding
3. Issues for Consideration:
   1. Patients prescribed a benzodiazepine, a non-benzodiazepine sedative hypnotic or a monoamine oxidase inhibitor are eligible to receive esketamine; however, it is advised that concurrent use while receiving esketamine may cause sedation or blood pressure changes
   2. Carefully review prior to use of esketamine, patients who are less than 6 months in remission from a substance use disorder
   3. May cause fetal Consider pregnancy planning and prevention in females of reproductive age.