Optum By United Behavioral Health Florida Medicaid Managed Medical Assistance (MMA) Level of Care Guidelines

Transcription

1 Optum By United Behavioral Health 2015 Florida Medicaid Managed Medical Assistance (MMA) Level of Care Guidelines (PSR) services combine daily medication use, independent living and social skills training, support to members and their families, housing, pre-vocational and transitional employment rehabilitation training, social support and network enhancement, structured activities to diminish tendencies towards isolation and withdrawal and teaching of the recipient and family about symptom management, medication and treatment options. Psychosocial Rehabilitation services are collaborative, person-directed, individualized, and based on the member s capacity for recovery. describes activities that are intended to restore a member s skills and abilities essential for independent living. Activities include development and maintenance of necessary daily living skills; food planning and preparation; money management; maintenance of the living environment; and training in appropriate use of community services. Activities vary in intensity, frequency, and duration in order to support members in managing functional difficulties, or to otherwise realize recovery goals. is designed to assist the member to compensate for or eliminate functional deficits and interpersonal and environmental barriers created by their disabilities, and to restore social skills for independent living and effective life management. Ultimately, promotes recovery, community integration, and a higher quality of life. may be provided in conjunction with traditional pharmacologic and psychotherapeutic interventions. However, differs from traditional pharmacologic and psychotherapeutic intervention in that it concentrates less upon the amelioration of symptoms and more upon restoring functional capabilities. The service may also be used to facilitate cognitive and socialization skills necessary for functioning in a work environment focusing on maximum recovery and independence. It includes work readiness assessment, job development on behalf of the member, job matching, on the job training, and job support. services may be provided in a facility, home, or community setting. Optum is a brand used by United Behavioral Health and its affiliates.

2 INSTRUCTIONS FOR USE Optum s Level of Care Guidelines are used to standardize coverage determinations, promote evidence-based practices, and support member s recovery, resiliency, and wellbeing. Optum s Level of Care Guidelines are derived from generally accepted standards of behavioral health practice. These standards include guidelines and consensus statements produced by professional specialty societies, as well as guidance from governmental sources such as CMS National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs). While this Level of Care Guideline does reflect Optum s understanding of current best practices in care, it does not constitute medical advice. Optum reserves the right, in its sole discretion, to modify its Level of Care Guidelines as necessary. 1. Admission Criteria 1.1. The member is eligible for benefits The member s current signs and symptoms meet criteria for a covered behavioral health condition The why now factors that precipitated admission (e.g., changes in the member s signs and symptoms, psychosocial and environmental factors, or level of functioning) indicates that the member requires assistance with restoring skills and abilities essential for independent living including those related to: Education or work; Finances; Housing; Health/medical; Social needs; Basic living skills; Legal needs The member is not in imminent risk of harm to self or others and/or property Co-occurring behavioral health and medical conditions can be safely managed. 2

3 1.6. Services are medically necessary. A service is medically necessary when it meets the following conditions: The service is necessary to protect life, prevent significant illness or significant disability, or is to alleviate pain The service is individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment The service is consistent with generally accepted professional medical standards as determined by the Medicaid program, and is not experimental or investigational The service reflects the level of service that can be safely furnished, and for which no equally effective and more conservative or less costly treatment is available statewide The service is furnished in a manner, not primarily intended for the convenience of the recipient, the recipient s caretaker, or the provider The fact that a provider has prescribed, recommended, or approved medical or allied care, goods, or services, does not, in itself, make such are, goods or services medically necessary or a covered service Services are not considered to be medically reasonable when the member has a Neurocognitive Disorder (dementia or delirium) or other psychiatric or neurological conditions that have produced a cognitive deficit severe enough to prohibit benefit to the member Participation in PSR is not solely for the purpose of satisfying legal requirements for treatment or services. 2. Continued Service Criteria 2.1. The admission criteria are still met and active treatment is being provided. For treatment to be considered active services must be Supervised and evaluated by the admitting provider; Provided under an individualized treatment plan that is focused on the why now factors, and makes use of clinical best practices; 3

4 Reasonably expected to improve the member s presenting problems within a reasonable period of time Services continue to be medically necessary The why now factor leading the member to access PSR have been identified and are integrated into the rehabilitation plan Clinical best practices are being provided with sufficient intensity to address the member s treatment needs The member s family and other natural resources are engaged to participate in PSR as clinically indicated. 3. Discharge Criteria 3.1. The continued stay criteria are no longer met. Examples include: Active treatment is not being provided Services are no longer medically necessary The why now factors which led the member to access PSR have been addressed to the extent that the member no longer requires the support of PSR. OR 3.2. The member is unwilling or unable to participate in PSR The member moves outside the geographic area of the program s responsibility. 4. Clinical Best Practices OR 4.1. Evaluation and Rehabilitation Planning PSR services are organized around: The member s stated goals The member s preferences The identified needs of the member Improving the ability of the member to understand their needs Assisting the member to achieve their goals in the following areas: 4

5 Community living skills including food planning and preparation, money management, maintenance of the living environment; Interpersonal relations; Recreation or use of leisure time activities; Vocational development or employment; Educational development; Self-advocacy; Access to non-disability related social resources The responsible provider in conjunction with the rehabilitation team completes the initial evaluation of the following upon admission: The why now factors which led the member to access PSR The member s readiness for rehabilitation The member s overall rehabilitation goal The member s functional skills and knowledge in relation to the overall rehabilitation goal The member s resources in relation to the overall rehabilitation goal The initial evaluation also includes an assessment of harm to self, others, and/or property In the event that not all information is available at the time of the evaluation, there must be enough information to guide development of the rehabilitation plan, and support the need for PSR The provider informs the member of safe and effective treatment alternatives, as well as the potential risks and benefits of the proposed treatment. The member gives informed consent acknowledging willingness and ability to participate in treatment and abide by safety precautions The responsible provider in conjunction with the rehabilitation team and, whenever possible, the member develops a multidisciplinary rehabilitation plan that addresses the why now factors that led to PSR, and focuses on the following: The member s rehabilitation goal; The member s present level of skills and knowledge relative to the rehabilitation goal; 5

6 The skills and knowledge needed to achieve the member s rehabilitation goal; The member s present resources and the resources needed to achieve the member s rehabilitation goal The rehabilitation plan includes specific and measurable objectives aimed at assisting the member with achieving the rehabilitation goal, and interventions for each skill, knowledge, or resource objective The rehabilitation plan may be informed by the findings of the initial clinical evaluation When the initial assessment identifies a potential risk of harm to self, others, and/or property a personal safety plan is completed that includes: Triggers; Current coping skills; Warning signs; Preferred interventions; Advance directives, when available The provider documents a daily progress note that addresses each service provided The provider in conjunction with the rehabilitation team and, whenever possible, the member conducts a formal review of the rehabilitation plan at least every 6 months. The rehabilitation plan is reviewed more often than once every 6 months when significant changes such as the following occur: A change in the member s condition A change in participation in PSR A change in utilization of services outside of PSR (e.g., the Emergency Room) The program provides an effective system for reaching out to members who are not attending, becoming isolated, or who are hospitalized The program collaborates with other providers and agencies to coordinate services and referrals that support the member s engagement Discharge Planning The provider and the member develop an initial discharge plan when the member accesses PSR. 6

7 The provider and the member update the initial discharge plan in response to completion of goals ensuring that: An appropriate discharge plan is in place prior to discharge; The discharge plan is designed to mitigate the risk that the why now factors which precipitated access to PSR will reoccur; and The member agrees with the discharge plan The discharge plan: Identifies the member s progress meeting their rehabilitation goal Identifies the plan for services and supports needed to further assist the member with community integration, recovery, and realizing a higher quality of life Includes information on the continuity of the member s medications For members remaining in the program s geographic area of responsibility, the provider: Shares the discharge plan and all pertinent information with other providers delivering services to the member prior to discharge Provides the member with information about: Recommended self-help and community resources; and How the member can resume PSR For members moving outside the program s geographic area of responsibility, the provider discusses the need for and availability of PSR with the member. As needed, the program assists the member with accessing PSR in the member s new service area. The provider maintains contact with the member through the transition. References 1. Anthony, W.A., & Farkas, M.D. (2009). Primer on the Psychiatric Rehabilitation Process. Boston: Boston University Center for Psychiatric Rehabilitation. 2. Commission on Accreditation of Rehabilitation Facilities. Behavioral Health Standards Manual, Tucson, AZ; CARF International, Lyman, DR, Kurtz, MM, Farkas, M, et al. (2014). Skill building: Assessing the evidence. Psychiatric Services, 65,

8 4. McGuire, AB, Kukla, M, Green, A, et al. (2014). Illness management and recovery: A review of the literature. Psychiatric Services, 65, State of Florida, Administrative Code. (2006). Rule 59G (166), Definitions. Retrieved from MEDICAID&ID=59G State of Florida, Agency for Health Care Administration. (2014). Florida Medicaid: Community Behavioral Health Services Coverage and Limitations Handbook. Retrieved from 7. Substance Abuse and Mental Health Services Administration. (2009). Illness management and recovery: Practitioner guides and handouts. Retrieved from: Recovery-Evidence-Based-Practices-EBP-KIT/SMA Winarski, J., Thomas, G., Dhont, K., & Ort, R. (2006). Recovery-Oriented Medicaid Services for Adults with Severe Mental Illness. Tampa FL: Louis de la Parte Florida Mental Health Institute. University of South Florida. 8