Inpatient Behavioral Health and Inpatient Substance Abuse Treatment: Aligning Care Efficiencies with Effective Treatment

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1 Inpatient Behavioral Health and Inpatient Substance Abuse Treatment: Aligning Care Efficiencies with Effective Treatment BHM Healthcare Solutions

2 Presentation Objectives Attendees will have a thorough understanding of Inpatient Behavioral Health and Inpatient Substance Abuse Treatment (IP) from an authorization perspective Attendees will gain an understanding of the importance of Medical Necessity Criteria as it applies to Inpatient Behavioral Health and Inpatient Substance Abuse Treatment Attendees will learn key questions to ask through the authorization process BHM Healthcare Solutions

3 Understanding Medical Necessity Criteria (MNC) According to a presentation by NC Department of Health and Human Services (Division of Medical Assistance) Medical necessity is individual, but some generally accepted components are: Intended to prevent, diagnose, correct, cure, alleviate, or preclude deterioration of a diagnosable condition that threatens life, causes pain or suffering, or results in illness or infirmity Treatment is expected to improve the condition or levels of functions in relationship to the presenting diagnosis BHM Healthcare Solutions

4 Understanding Medical Necessity Criteria (MNC) According to a presentation by NC Department of Health and Human Services (Division of Medical Assistance) Medical Necessity Essential and consistent with nationally acceptable standard of practice Individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the recipient s needs Can be safely furnished, and no equally and more conservative or less costly treatment is available statewide Is furnished in a manner not primarily intended for the convenience of the recipient, the recipient s caretaker, or the provider BHM Healthcare Solutions

5 Understanding Inpatient Behavioral Health Services Inpatient Behavioral Health services provide hospital treatment in a hospital setting 24 hours per day. Supportive nursing and medical care are provided under the supervision of a psychiatrist or a physician. This service is designed to provide continuous treatment for beneficiaries with acute psychiatric problems and/or acute substance abuse problems. BHM Healthcare Solutions

6 They are appropriate for members whose acute biomedical and emotional, behavioral or cognitive problems are so severe that they require primary medical and nursing care. Understanding Inpatient Behavioral Health Services BHM Healthcare Solutions

7 Understanding Inpatient Behavioral Health Services This level of care (LOC) is intended to accomplish the following: Attain a level of functioning (stabilization of psychiatric symptoms and/or the establishment of abstinence) sufficient to allow for mental health or substance abuse treatment in a less restrictive environment Provide the patient and their parents/support system the opportunity to become informed participants through the course of hospitalization and aftercare Ensure linkage to lower levels of care (eventually community based) BHM Healthcare Solutions

8 Understanding Inpatient Behavioral Health Services This intensive LOC includes, but is not limited to, the following face-to-face and structured interventions as clinically indicated: Medication management Individual and family psychotherapy Group therapy Dual diagnosis treatment for psychiatric and substance abuse disorders Developing and Implementing a step down behavioral support plan with the patient and the patient s caregivers BHM Healthcare Solutions

9 All criteria must be met for admission: Managing Care: IP BH Services Admission Criteria (Child and Adolescent) A. The beneficiary shall meet criteria for one or more of the following DSM-IV Diagnoses: 1. Beneficiary is presently danger to self (e.g., engages in self-injurious behavior, has a significant potential, or is acutely manic). This usually would be indicated by one of the following: a. Beneficiary has made a suicide attempt or serious gesture (e.g. Overdose, hanging, jumping from or placing self in front of moving vehicle, self-inflicted gunshot wound), or is threatening same with likelihood of acting on the threat, and there is an absence of supervision or structure to prevent suicide of the beneficiary who has made an attempt, serious gesture or threat. b. Beneficiary manifests a significant depression, including current contemplation of suicide or suicidal ideation, and there is an absence of supervision or structure to prevent suicide. c. Beneficiary has a history of affective disorder: I. with mood which has fluctuated to the manic phase, OR II. has destabilized due to stressors or non-compliance with treatment. BHM Healthcare Solutions

10 Managing Care: IP BH Services Admission Criteria (Child and Adolescent) All criteria must be met for admission: d. Beneficiary is exhibiting self-injurious (cutting on self, burning self) or is threatening same with likelihood of acting on the threat; OR 2. Beneficiary engages in actively violent, aggressive or disruptive behavior or beneficiary exhibits homicidal ideation or other symptoms which indicate the beneficiary is a probable danger to others. This usually would be indicated by one of the following: a. Beneficiary whose evaluation and treatment cannot be carried out safely or effectively in other settings due to impulsivity, impaired judgment, severe oppositional behavior, running away, severely disruptive behaviors at home or school, self-defeating and self endangering activities, antisocial activity, and other behaviors which may occur in the context of a dysfunctional family and may also include physical, psychological, or sexual abuse. b. Beneficiary exhibits serious aggressive, assaultive, or sadistic behavior that is harmful to others (e.g., assaults with or without weapons, provocations of fights, gross aggressive over-reactivity to minor irritants, harming animals or is threatening same with likelihood of acting on the threat. This behavior should be attributable to the beneficiary s specific DSM-IV diagnosis and can be treated only in a hospital setting; OR BHM Healthcare Solutions

11 Managing Care: IP BH Services Admission Criteria (Child and Adolescent) All criteria must be met for admission: 3. Acute onset of psychosis or severe thought disorganization or clinical deterioration in condition of chronic psychosis rendering the beneficiary unmanageable and unable to cooperate in treatment. This usually would be indicated by ONE of the following: Beneficiary has recent onset or aggravated psychotic symptoms (e.g., disorganized or illogical thinking, hallucinations, bizarre behavior, paranoia, delusions, incongruous speech, severely impaired judgment) and is resisting treatment or is in need of assessment in a safe and therapeutic setting; OR 4. Presence of medication needs, or a medical process or condition, which is life threatening (e.g., toxic drug level) or which requires the acute care setting for its treatment. This usually would be indicated by ONE of the following: a. Proposed treatments require close medical observation and monitoring to include, but not limited to, close monitoring for adverse medication effects, capacity for rapid response to adverse effects, and use of medications in clients with concomitant serious medical problems. b. Beneficiary has a severe eating disorder or substance abuse disorder, which requires 24-hour-a-day medical observation, supervision, and intervention. BHM Healthcare Solutions

12 All criteria must be met for admission: Managing Care: IP BH Services Admission Criteria (Child and Adolescent) 5. Need for medication therapy or complex diagnostic evaluation where the client s level of functioning precludes cooperation with the treatment regimen, including forced administration of medication. This usually would be indicated by ONE of the following: a. Beneficiary whose diagnosis and clinical picture is unclear and who requires 24 hour clinical observation and assessment by a multidisciplinary hospital psychiatric team to establish the diagnosis and treatment recommendations. b. Beneficiary is involved in the legal system (e.g., in a detention or training school facility) and manifests psychiatric symptoms (e.g., psychosis, depression, suicide attempts or gestures) and requires a comprehensive assessment in a hospital setting to clarify the diagnosis and treatment needs; AND B. A provider team shall certify that the beneficiary meets each of the certification of need requirements listed at 42 CFR BHM Healthcare Solutions

13 Managing Care: IP BH Services Admission Criteria (Child and Adolescent) B. A provider team shall certify that the beneficiary meets each of the certification of need requirements listed at 42 CFR To meet the federal requirement at 42 CFR , all of the following must apply: (a) Ambulatory care resources available in the community do not meet the treatment needs of the recipient. (b) Proper treatment of the recipient s psychiatric condition requires services on an inpatient basis under the direction of a physician. (c) The services can reasonably be expected to improve the recipient s condition or prevent further regression so that services will no longer be needed. BHM Healthcare Solutions

14 Areas to Focus On In NC, hospitals are required to submit the initial request for authorization within 48 hours of admission for Medicaid requests. The member must meet the clinical criteria for imminent dangerousness to self and/or others, be acutely psychotic, in need of detox, or have medication or diagnostic needs that cannot be safely treated in a lower level of care. BHM Healthcare Solutions

15 All of the following criteria must be met: Managing Care: IP Preadmission Review Criteria for Substance Abuse for Medicaid Beneficiaries (Ages 21 64) A. Any DSM-IV diagnosis of substance abuse or dependency AND ONE of the following: 1. Need for skilled observation (including instance of coma or stupor) or therapeutic milieu necessitating inpatient treatment. 2. Need for detoxification and not manageable by alternative treatment 3. Potential danger to self or others and not manageable by alternative treatment 4. Onset of, or impending, convulsions or delirium tremens or toxic psychosis 5. Presence of significant medical disorder or other disabling psychiatric disorder necessitating inpatient treatment B. This is used in combination with American Society of Addiction Medicine (ASAM) criteria when appropriate. BHM Healthcare Solutions

16 Dimensional Admission Criteria for Substance Abuse (Adult) Direct admission to a Level IV program is available for the adult who meets the instability specifications in Dimension 1 (acute intoxication and /or withdrawal) OR Dimension 2 (biomedical conditions or problems) OR Dimension 3 (emotional, behavioral or cognitive conditions). A member s problems in Dimensions 4, 5, and 6 do not need to be met. DIMENSION 1: Acute Intoxication and/or Withdrawal DIMENSION 2: Biomedical Conditions and Complications DIMENSION 3: Emotional, Behavioral or Cognitive Conditions and Complications DIMENSION 4: Readiness to Change DIMENSION 5: Relapse, Continued Use or Continued Problem Potential DIMENSION 6: Recovery Environment BHM Healthcare Solutions

17 Dimensional Admission Criteria for Substance Abuse (Adult) DIMENSION 1: Acute Intoxication and/or Withdrawal 1. Member must be experiencing or at risk of experiencing acute withdrawal, and requires intensive medical management DIMENSION 2: Biomedical Conditions and Complications 1. Member s biomedical conditions are severe and require 24-hour medical and nursing care 2. Member s biomedical conditions are severe enough to distract from treatment at a less intensive level of care BHM Healthcare Solutions

18 Dimensional Admission Criteria for Substance Abuse (Adult) DIMENSION 3: Emotional, Behavioral or Cognitive Conditions 1. The member s status in Dimension 3 is characterized by at least one of the following: a. Dangerousness/Lethality- severe risk of harm to self or others b. Interference with Recovery Efforts- very severe-almost to overwhelming interference renders the member incapable of participating in treatment at a less intensive level of care c. Social Functioning symptoms are causing very severe, dangerous impairment and requires frequent medical monitoring d. Ability for Self Care experiencing very severe difficulties with activities of daily living e. Course of Illness history and present condition suggests that emotional, behavioral, cognitive conditions will be unstable without monitoring DIMENSION 4: Readiness to Change 1. The member s problems in this dimension do not qualify him or her for a level IV service BHM Healthcare Solutions

19 Dimensional Admission Criteria for Substance Abuse (Adult) DIMENSION 5: Relapse, Continued Use or Continued Problem Potential 1. The member s problems in this dimension do not qualify him or her for a Level IV service. DIMENSION 6: Recovery Environment 1. The member s problems in this dimension do not qualify him or her for a Level IV service. BHM Healthcare Solutions

20 Remember.. Areas to Focus On Assess the severity of symptoms and determine whether the member can safely be treated on a lower level of care. ASAM Criteria is NOT to be used solely but in conjunction with the Preadmission Review Criteria for Substance Abuse (there are 5 and the member must meet one of these). BHM Healthcare Solutions

21 Preadmission Review Criteria for Non-Substance Abuse for Medicaid Beneficiaries (ages 21-64) (Adult) The following are criteria for preadmission review for psychiatric treatment of adult non-substance abuse and all other conditions: Any DSM-IV Axis I or II diagnosis AND ONE of the following: a. Impaired reality testing (e.g., delusions, hallucinations), disordered behavior or other acute disabling symptoms not manageable by alternative treatment b. Potential danger to self or others and not manageable by alternative treatment c. Concomitant severe medical illness or substance abuse necessitating inpatient treatment d. Severely impaired social, familial, occupational or developmental functioning that cannot be effectively evaluated or treated by alternative treatment e. Failure of or inability to benefit from alternative treatment, in the presence of severe disabling psychiatric illness f. Need for skilled observation, special diagnostic or therapeutic procedures or therapeutic milieu necessitating inpatient treatment BHM Healthcare Solutions

22 Areas to Focus On Focus on the following: Why now? This may be a chronic state or something could have happened to cause the patient to decompensate suddenly. What the patient is saying or doing that requires this level of care must be documented. Give specifics What does the member s baseline level of functioning look like? Assess their support system. What previous treatment have they had? What did or did not work? What is needed for this member to improve? BHM Healthcare Solutions

23 Managing Care: IP BH Services Continued Stay Criteria All criteria must be met: A. The beneficiary has one of the following: 1. Presence of a current DSM-IV, Axis I diagnosis; OR 2. Presence of a current DSM-IV, Axis II diagnosis AND current symptoms/behaviors which are characterized by ALL of the following: a. Symptoms or behaviors are likely to respond positively to acute inpatient treatment; AND b. Symptoms or behaviors are not characteristic of patient s baseline functioning* ; AND c. Presenting problems are an acute exacerbation of dysfunctional behavior patterns, which are recurring and resistive to change. BHM Healthcare Solutions

24 All criteria must be met: Managing Care: IP BH Services Continued Stay Criteria (cont.) B. Symptoms are not due solely to intellectual disability. C. The symptoms of the beneficiary are characterized by: 1. At least one of the following: a. Endangerment of self or others; OR b. Behaviors which are grossly bizarre, disruptive, and provocative (e.g. feces smearing, disrobing, pulling out hair); OR c. Related to repetitive behavior disorders which present at least five times in a 24-hour period; OR d. Directly result in an inability to maintain age appropriate roles; AND BHM Healthcare Solutions

25 All criteria must be met: Managing Care: IP BH Services Continued Stay Criteria (cont.) 2. The symptoms of the beneficiary are characterized by a degree of intensity sufficient to require continual medical/nursing response, management, and monitoring. D. The services provided in the facility can reasonably be expected to improve the beneficiary s condition or prevent further regression so that treatment can be continued on a less intensive level of care, and proper treatment of the beneficiary s psychiatric condition requires services on an inpatient basis under the direction of a physician. BHM Healthcare Solutions

26 Areas To Focus On The member s symptoms: The symptoms of the beneficiary are characterized by a degree of intensity sufficient to require continual medical/nursing response, management, and monitoring Must be likely to respond well to treatment Are not characteristic of their baseline functioning (i.e. Intellectual Disability) Are an ACUTE exacerbation of dysfunctional behavioral patterns. Must have a high degree of intensity such that they cannot be managed safely on a lower level of care BHM Healthcare Solutions

27 Managing Care: IP BH Services Continued Stay Criteria (cont.) A Discharge Plan is a Deferred Treatment Plan and should be as specific and concrete as a Treatment Plan BHM Healthcare Solutions

28 Understanding Discharge The member s discharge date, and discharge plan are crucial elements in mapping out the care plan Reviewers should view the discharge plan as the end goal of treatment and evaluate whether the level of care prescribed is furthering the discharge goal according to the timeline ALWAYS ASK, What is the estimated discharge date and plan! BHM Healthcare Solutions

29 Contact Information Lynnette Gordon UM Director Phone: Network Operations Member specific questions or requesting a peer to peer BHM Healthcare Solutions

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