Clinical Criteria Inpatient Medical Withdrawal Management Substance Use Inpatient Withdrawal Management (Adults and Adolescents)

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1 4.201 Inpatient Medical Withdrawal Management Substance Use Inpatient Withdrawal Management (Adults and Adolescents) Description of Services: Inpatient withdrawal management is comprised of services that are provided in an appropriately licensed acute care general, psychiatric or specialty hospital for the purpose of completing a medically safe withdrawal from substances. Inpatient detoxification is typically indicated when there is an imminent risk of severe, life threatening withdrawal symptoms and/or co-occurring medical or mental health conditions that preclude safe detoxification in a less intensive setting. Acute inpatient withdrawal management represents the most intensive level of care. Multidisciplinary assessments and multimodal interventions are provided in a 24-hour secure and protected, medically staffed and psychiatrically supervised treatment environment. Inpatient service settings must provide an initial visit with an attending physician within 24 hours of admission for evaluation and treatment planning, and a documented daily visit with an attending licensed prescribing provider. Clinically based facility exceptions to the daily prescribing provider visit requirement may be approved by a Beacon Health Options Medical Director based on founded requests (geographic considerations, provider access/availability, etc.). Granted exceptions must nevertheless provide a documented visit with an attending licensed prescriber a minimum of 5 days per week, no less than every 48 hours, and no less than within 24 hours of discharge. Twenty-four hour skilled nursing care, daily medical evaluation and management, and a structured treatment milieu are required. The goal of acute inpatient withdrawal management is to medically stabilize individuals who are in imminent or acute withdrawal until they can be treated in a lower level of care. Treatment should include physician approved protocols and policies to manage the withdrawal process. Another goal of inpatient detoxification is to address denial and acceptance, engage the family, and begin addressing triggers and coping skills. Active family/significant other involvement is important and a discharge care plan should be developed unless contraindicated. Estimated length of stay is based on individual needs which must be documented in the treatment plan. Licensure and credentialing requirements specific to facilities and individual practitioners do apply and are found in our provider manual/credentialing information. Additional information for adolescent individuals: In general the medical necessity for the treatment of substance abuse disorders for adolescents is similar to that of adults. However, in considering the following criteria several factors unique to the adolescent population should be taken into consideration. Physiological dependence is less common and attention should be given to the cognitive and emotional developmental aspects, any neurodevelopmental issues, and family support/supervision. In addition, an important area of focus is the individual s external peer group (friends, schoolmates etc.), availability of school-based drug prevention programs and how they affect the accomplishment of a successful outcome. Also it is necessary to focus on problem solving skills, relapse prevention, social skills and academics as they relate to the individual individual s treatment. The development of a social support network that enhances the likelihood of successful treatment and maintained sobriety requires careful coordination amongst the treatment team, parents and individual. In general, coexisting medical issues requiring higher levels of care are less common in adolescents. Important: While level of care determinations are considered in the context of an individual's treatment history; Beacon Health Options never requires the attempt of a less intensive treatment as a criterion to authorize any service. Reviewed: 11/19/12, 11/18/13, 11/17/14, 2/5/15 Page 1 of 6

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3 Admission Criteria Criteria The following criterion is necessary for determination: 1. Individual has been evaluated by a licensed clinician and meets diagnostic criteria under DSM (the most current version of the DSM) for Substance Dependence which requires and can reasonably be expected to respond to detoxification treatment. 2. Facility demonstrates ability to safely treat patients with quality care by being in Beacon Health Options network or being accredited by one of the organizations listed in N206. All of the following criteria must also be met: 3. The individual s use of alcohol and/or other drugs is significant and persistent, and discontinuation is associated with any of the following: a. Current symptoms of severe, potentially life threatening withdrawal requiring 24-hour medical supervision and management. This does not include the patient having mere physical or mental discomfort. b. The individual s history of use, history of severe withdrawal (such as seizures or actual Delirium Tremens), or presenting condition indicates that severe withdrawal is imminent and requires 24-hour medical supervision and management. c. Presence of a serious, unstable medical or mental health condition that is likely to complicate detoxification to the extent that 24 hour observation and intervention is necessary. d. Potential risk of serious harm to self or others complicating the detoxification to the extent that a 24 hour acute setting is required for the individual s safety (assessment to include risk, intent, plans, mitigating factors). 4. There are significant medical complications from drug and/or alcohol use that require 24-hour monitoring and nursing care and can be safely managed in an inpatient detoxification program. 5. Blood and/or urine drug screen was (will be) ordered upon admission. 6. CIWA-Ar score at least 10 (or an equivalent severity score on a similar standardized scoring system). It is expected that the following takes place: 7. The individualized treatment plan needs to be evidence based and address psychological, social, medical, substance abuse, and aftercare needs and clearly state the benefits individual will receive in program, and the goals of treatment cannot be based solely on need for structure and lack of supports. Reviewed: 11/19/12, 11/18/13, 11/17/14, 2/5/15 Page 3 of 6

4 Psychosocial, Occupational, and Cultural and Linguistic Factors Exclusion Criteria Continued Stay Criteria 8. Treatment interventions are guided by quantitative measures of withdrawal such as the CIWA-Ar or COWS. 9. The multi-disciplinary discharge planning process starts from the assessment and includes the patient and family/significant other as appropriate, unless contraindicated secondary to risk of harm to patient or family/support. These factors, as detailed in the Introduction, may change the risk assessment and should be considered when making level of care decisions. Any of the following criteria is sufficient for exclusion from this level of care: 1. The individual can be safely maintained and effectively treated at a less intensive level of care. 2. Symptoms result from a medical condition which warrants a medical/surgical setting for treatment. 3. Symptoms result from a psychiatric condition which warrants a locked psychiatric unit due to danger to self or other. For individuals where imminent risk is also a concern due to detoxification the psychiatric unit should be equipped to manage the detoxification as well as maintain patient safety from the psychiatric condition. 4. The primary problem is social, economic (e.g., housing, family conflict, etc.), or one of physical health without a concurrent substance dependency episode meeting criteria for this level of care, or admission is being used as an alternative to incarceration. 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 for inpatient care, acute treatment interventions (including pharmacological) have not been exhausted, and no other less intensive level of care would be adequate. 2. There continue to be physical signs and symptoms of acute withdrawal (or risk thereof) that indicate 24 hour care is still necessary. 3. The patient continues to present with unstable co-morbid medical or mental health conditions that are likely to complicate the management of withdrawal to the degree that the patient s life would be endangered at a lower level of care. 4. The multi-disciplinary discharge planning process starts from the initial assessment and includes the patient and family/significant other as appropriate unless contraindicated secondary to risk of harm to patient or family/support. 5. Treatment planning is individualized and appropriate to the individual s changing condition with realistic and specific goals and objectives stated. Reviewed: 11/19/12, 11/18/13, 11/17/14, 2/5/15 Page 4 of 6

5 Discharge Criteria Clinical Criteria Treatment planning should include active family or other support systems, social, occupational and interpersonal assessment with involvement unless contraindicated. Family sessions need to occur in a timely manner. Treatment planning goals should be realistic, measurable, and attainable. Expected benefits from all relevant modalities, including family and group treatment are documented. Treatment plan must include individual s own stated goals of treatment. 6. All services and treatment are carefully structured to achieve optimum results in the most time-efficient manner possible consistent with sound clinical practice. 7. Documentation of signs and symptoms must be noted. The frequency for checking vital signs is dependent on the severity of an individual s withdrawal symptoms. This frequency may range from as often as every 30 min for the highest acuity to once every 8 hours for those ready to discharge. 8. Progress has been communicated by the provider in clear measureable physiological responses related to the target symptoms. Or goals of treatment have not yet been achieved, but adjustments in the treatment plan to address lack of progress and/or psychiatric/medical complications are evident. 9. Care is rendered in a clinically appropriate manner and focused on the individual s behavioral and functional outcomes as described in the discharge plan. 10. When medically necessary, appropriate psychopharmacological intervention has been prescribed and/or evaluated and consistent with prescribing guidelines. 11. Patient is actively participating in plan of care and treatment to the extent possible consistent with his/her condition. 12. Coordination with relevant outpatient providers is implemented (including PCP, MHSA provider or twelve-step program as needed). Any of the following criteria are sufficient for discharge from this level of care 1. The individual has been stabilized and is no longer at imminent risk from withdrawal symptoms. 2. Treatment plan goals and objectives have been substantially met and/or a safe, continuing care program can be arranged and deployed at a lower level of care. Follow-up aftercare appointment is arranged for a timeframe consistent with the individual s condition and applicable standards. 3. The individual no longer meets admission criteria or meets criteria for a less intensive level of care. 4. The patient initially presented with co-morbid medical conditions that are likely to complicate the management of withdrawal to the degree that the Reviewed: 11/19/12, 11/18/13, 11/17/14, 2/5/15 Page 5 of 6

6 patient s life would be endangered at a lower level of care. However the unstable co-morbid medical condition has been controlled to the point where treatment at a lower level of care is appropriate. 5. The individual, family, legal guardian and/or custodian are competent but non- participatory in treatment or in following program rules and regulations. 6. The non-participation is 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. 7. Support systems that allow the patient to be maintained in a less restrictive treatment environment have been thoroughly explored and/or secured. 8. The individual's physical condition necessitates transfer to a medical facility. Reviewed: 11/19/12, 11/18/13, 11/17/14, 2/5/15 Page 6 of 6