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

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1 Optum By United Behavioral Health 2015 Florida Medicaid Managed Medical Assistance (MMA) Level of Care Guidelines Statewide Inpatient Psychiatric Program Services (SIPP) Statewide Inpatient Psychiatric Program Services are sub-acute medical and mental health-related services provide by or under the direction of professional or technical personnel, in an institution that is privately owned, licensed as a psychiatric hospital or residential treatment center for children and adolescents and enrolled as a SIPP provider in the Florida Medicaid program. SIPP serves high-risk Medicaid recipients under age 21 who require placement in a psychiatric residential setting due to a primary diagnosis of serious mental illness or emotional disturbance. Recipients served in SIPP typically require a level of service beyond that which is provided in community-based services or acute inpatient settings. SIPP is intended to stabilize and adequately resolve presenting problems and symptoms, incorporate permanency, design effective aftercare treatment plans, and ensure coordination with State agencies and community services where applicable with the goals of reducing recidivism and relapse, and reducing the length and frequency of acute inpatient admissions. 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. Optum is a brand used by United Behavioral Health and its affiliates.

2 1. Admission Criteria 1.1. The member is under age 21 and is eligible under one of the following Medicaid eligibility categories: TANF-related Supplemental Security Income (SSI) SSI-related 1.2. If under the care and custody of the State, the child has been assessed by a qualified evaluator, and the need for SIPP is indicated. OR 1.3. If in parental custody, the child has been assessed by a psychologist or psychiatrist, and the assessment has determined that the child has an emotional disturbance i or a serious emotional disturbance ii 1.4. All available treatment that is less restrictive than residential treatment has been considered or is unavailable. The member s current condition cannot be safely, efficiently and effectively addressed and/or treated in a less intensive setting due to changes in the member s signs and symptoms, level of functioning, and/or psychosocial and environmental factors (i.e., the why now factors leading to admission) Failure of treatment in a lower level of care is not a prerequisite for authorizing coverage Treatment is reasonably likely to resolve the child s presenting problem Services are medically necessary iii 2. Continue Service Criteria 2.1. The admission criteria are still met, and active treatment iv is being provided The why now factors leading to admission have been identified and are integrated into the treatment and discharge plans Clinical best practices are being provided timely with sufficient intensity to address the member s treatment needs. 2

3 2.4. The member s parent or guardian is engaged to participate in treatment as clinically indicated. 3. Discharge Criteria 3.1. The continued service criteria are no longer met. Examples include: The why now factors which led to admission have been addressed to the extent that the member can be safely transitioned to a less intensive level of care, or no longer requires treatment Active treatment is not being provided The member requires care that is primarily social, custodial, recreational or for purposes of respite The member requires treatment in a medical-surgical setting The member is unwilling or unable to participate in treatment. 4. Clinical Best Practices 4.1. Evaluation and Treatment Planning Prior to admission, the member s parent or guardian should receive an explanation of why SIPP is being recommended. The explanation should include the nature, purpose and expected length of treatment. The member s parent or guardian should also be informed of safe and effective treatment alternatives, potential risks and benefits of SIPP. This information is provided so that the member s parent or guardian can give informed consent The provider collects information from the member and other sources, and completes an initial evaluation of the following: The member s chief complaint; A description of the acute condition or exacerbation of a chronic condition; The why now factors; The member s psychiatric and social histories including the histories of substance use and trauma; The history of treatment; Psychosocial and environmental problems; Mental status examination; Physical examination (when appropriate); Risk factors including those related to harm to self or others, as well as risk stemming from co-occurring behavioral health or medical conditions; Assessment of the member s coping strategies; 3

4 The member and parent or guardian s understanding of the need for change as context for treatment planning including interventions that will promote informed decision-making and participation in care; Resilience factors; Recover and resiliency goals In that event that not all information is available at the time of evaluation, there must be enough information to provide a basis for the diagnosis, guide development of the treatment plan, and support the need for SIPP The provider uses the findings of the evaluation to assign a DSM/ICD diagnosis The treatment plan should: Be developed and implemented within 14 calendar days of admission; Be based on the findings of the initial evaluation; Be developed by a multidisciplinary team comprised of the following: Member; Member s psychiatrist; Psychiatric social workers; Registered Nurse, Occupational Therapist, or Licensed Psychologist; The member s parent; The member s legal representative; The targeted case manager; Guardian or Child Welfare or Community Based Care counselor; Primary clinician; Direct child care staff; Activities staff; School personnel; Regional care coordinator; Medicaid utilization management specialist; and Others who are involved in the care of the member; 4

5 State treatment objectives in terms that are measurable, functional, time-framed and directly related to the why now factors; Prescribe an integrated program of therapies, activities, and experiences designed to meet the objectives, and include the amount, frequency and duration of each component of the program; Include interventions such as psychoeducation or motivational interviewing designed when necessary to engage the member and/or the member s parent or guardian in treatment, promote informed decisions, and support the member s broader recovery and resiliency goals; Define how the member s family and other natural resources will participate in treatment when clinically indicated; Provide for on-site educational services Reflect coordination with the member s designated Child Welfare or Community Based Care counselor and permanency plan, if the member is in state custody and with any assigned Targeted Case Manager during the last 120 calendar days of a member s admission; Be focused on allowing the member s safe return to the family and community services as soon as possible including how treatment will be coordinated with other providers as well as with agencies or programs with which the member is involved; Include an initial formulation of the discharge plan The psychiatrist shall, at a minimum: Be on call 24 hours a day; Interview the member weekly to assess progress toward meeting treatment goals, or more often if medically necessary; Supervise treatment for members who are on psychotropic medications; Coordinate care with the member s primary care physician when indicated by the member s medical condition; and Attend member staffings The provider will deliver, at a minimum: individual session and 1 family therapy session weekly, based on best practices and accepted clinical guidelines and provided in accordance with the member s individual needs; 5

6 If the member is unable to participate in 60 minute sessions for family and individual therapy, shorter and more frequent sessions should be offered during the week to provide comparable intervention duration; When more appropriate to a member s developmental and cognitive style, the member may have weekly individual sessions with the behavior analyst in place of weekly individual therapy; Weekly group therapy services; Therapeutic home assignments to allow the member and the member s family to practice skills learned in the program; Assistance with helping the member and the member s parent learn to manage the member s behaviors in age appropriate ways The behavior analysts shall complete a behavioral review of any of the following: Members ages 10 and under (upon admission); Members with an IQ of 69 or below (upon admission); Members whose rate of time out is not decreasing in the time frame anticipated by the treatment team; As used here, time out does not include voluntary time outs that the member requests or initiates in the process of learning and practicing self-management of behavior; Members who have required the use of seclusion or restraint The behavioral review shall: Identify behaviors contributing to the need for residential treatment so it may be addressed in the treatment plan; Identify factors contributing to the need for time out, seclusion and restraint so early intervention measures can be taken; Assess the seriousness of the member s behavior and identify trends to determine if additional assessment or a behavior plan is necessary; and Ensure that the level of point system, if one is used, or other similar method is appropriate and understood by the member The behavior analyst must complete a Comprehensive Behavior Analysis Assessment on any of the following: 6

7 Any member who has been restrained at least 2 times within any 30-day period; Any member who has been in seclusion at least 3 times within a 30-day period; or Any member referred by the treatment team The Comprehensive Behavior Analysis Assessment shall: Describe the target behaviors; Identify the events, times and situations when the target behaviors occur and do not occur; Describe the antecedents and consequences controlling the target behaviors; Describe the assessment methods used; Describe the direct observation of the member; Display the data collected in graphic form; and Summarize the findings of the assessment and individualized recommendations The behavior analyst will develop a behavior plan in consultation with the treatment team The behavior analyst will train and monitor staff on the implementation of behavioral interventions and the collection of data Treatment should be active, individualized, family-centered, culturally sensitive, trauma-informed, and focused on problems that necessitated SIPP The treatment plan is reviewed every 30 days to determine if SIPP is required and to recommend changes in the plan as indicated by the member s overall adjustment. The treatment plan should be reviewed sooner when there has been a change in the member s condition, or the member s condition is not improving or it has worsened. When the member s condition has not improved or it has worsened, the reassessment should determine whether the diagnosis is accurate, the treatment plan should be modified, or the member s condition should be treated in another level of care Discharge Planning The provider begins discharge planning at the time of admission. Modifications to the discharge plan continue throughout treatment ensuring that: 7

8 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 admission will reoccur; and The member and the member s parent or guardian agree with the discharge plan The provider shall develop a detailed discharge plan that identifies treatment needs and provides access to resources There must be documentation of provider and community liaison activities carried out throughout the stay to promote a coordinated community transition and a well-developed aftercare plan Within 30 calendar days of the planned discharge, the primary therapist shall contact the following to coordinate discharge: The discharge setting; The member s school; The receiving treatment provider; The Regional Substance Abuse and Mental Health office; Other agencies, programs, or community services from which the member will receive assistance Within 1 week prior to discharge the provider will ensure that community supports and aftercare treatment services are in place. References 1. Armstrong, M., Blasé, K., Dailey, K., Larkins, M., Chen. R., & Reyes, F. (2003). Statewide Inpatient Psychiatric Program: Report 4 - June Tampa FL: University of South Florida, Louis de la Parte Florida Mental Health Institute. AHCA series, State of Florida, Administrative Code. (2008). 65E-9.008, Mental Health Program, Licensure of Residential Treatment Centers, Admission. Retrieved from 3. State of Florida, Administrative Code. (2008). 65E-9.009, Mental Health Program, Licensure of Residential Treatment Centers, Treatment Planning. Retrieved from 4. State of Florida, Administrative Code. (2008). 65E-9.010, Mental Health Program, Licensure of Residential Treatment Centers, Length of Stay. Retrieved from 8

9 5. State of Florida, Administrative Code. (2008). 65E-9.011, Mental Health Program, Licensure of Residential Treatment Centers, Discharge and Discharge Planning. Retrieved from State of Florida, Agency for Health Care Administration. (2014). Florida Medicaid: Statewide Inpatient Psychiatric Program Coverage and Limitations Handbook. Retrieved from i Per F.S an emotional disturbance is present when a child is diagnosed with a mental, emotional, or behavioral disorder of sufficient duration to meet one of the diagnostic categories specified in the most recent edition of the Diagnostic and Statistical Manual of the American Psychiatric Association, but who does not exhibit behaviors that substantially interfere with or limit his or her role or ability to function in the family, school, or community. The emotional disturbance must not be considered to be a temporary response to a stressful situation. The term does not include a child or adolescent who meets the criteria for involuntary placement. ii Per F.S a serious emotional disturbance is present when a child diagnosed as having a mental, emotional, or behavioral disorder that meets one of the diagnostic categories specified in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association; and exhibits behaviors that substantially interfere with or limit his or her role or ability to function in the family, school, or community, which behaviors are not considered to be a temporary response to a stressful situation. iii Rule 59G (166), Florida Administrative Code defines medically necessary or medical necessity as follows: The medical or allied care, gods, or services furnished or ordered must meet the following conditions: 1) be necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain 2) be individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the patient s needs 3) be consistent with generally accepted professional medical standards as determined by the Medicaid program, and not experimental or investigational 4) reflect the level of services that can be safely furnished, and for which no equally effective and more conservative or less costly treatment is available statewide 5) be 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 care, goods or services medically necessary or a covered service. iv Per 42 CFR Part 441inpatient psychiatric services must involve active treatment, which means implementation of a professionally developed and supervised individual plan of care, that is developed and implemented no later than 14 days after admission; and is designed to achieve the beneficiary's discharge from inpatient status at the earliest possible time. 9

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