Psychiatric Residential Treatment Facility (PRTF): Aligning Care Efficiencies with Effective Treatment. BHM Healthcare Solutions

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1 Psychiatric Residential Treatment Facility (PRTF): Aligning Care Efficiencies with Effective Treatment 1

2 Presentation Objectives Attendees will have a thorough understanding of Psychiatric Residential Treatment Facility (PRTF) Services from an authorization perspective Attendees will gain an understanding of the importance of Medical Necessity Criteria as it applies to PRTF Attendees will learn key questions to ask through the authorization process 2

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 of infirmity Treatment is expected to improve the condition or levels of functions in relationship to the presenting diagnosis 3

4 Understanding Medical Necessity Criteria (MNC) General Criteria Covered Medicaid shall cover procedures, products, and services related to this policy when they are medically necessary, and: a. the procedure, product, or service is individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the beneficiary s needs; b. the procedure, product, or service can be safely furnished, and no equally effective and more conservative or less costly treatment is available statewide; and c. the procedure, product, or service is furnished in a manner not primarily intended for the convenience of the beneficiary, the beneficiary s caretaker, or the provider. 4

5 Understanding PRTFs Psychiatric Residential Treatment Facilities (PRTFs) provide non-acute inpatient facility care for NC Medicaid recipients (under 21 years of age) who have a mental illness and/or substance abuse/dependency and need 24-hour supervision and/or specialized interventions 5

6 Understanding PRTFs PRTFs provide: Planned regimen of 24-hour professionally directed evaluation, observation, medical monitoring and addiction treatment in an inpatient setting. They are appropriate for adolescents whose subacute biomedical and emotional, behavioral or cognitive problems are so severe that they require inpatient treatment, but who do not need the full resources of an acute care hospital. 6

7 Direct admission to a Level III.7 program is available for the adolescent who meets two of Dimensions 1-6 with at least one of the stability specifications in Dimensions 1 (acute intoxication and /or withdrawal) OR Dimension 2 (biomedical conditions or problems) OR Dimension 3 (emotional, behavioral or cognitive conditions). Dimensional Substance Abuse Admission Criteria 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 7

8 Dimensional Admission Criteria: Level III.7 DIMENSION 1: Acute Intoxication and/or Withdrawal 1. The adolescent is experiencing or at risk of acute or sub acute intoxification or withdrawal with moderate to severe signs and symptoms. DIMENSION 2: Biomedical Conditions and Complications 1. The adolescents status is characterized by one of the following: a. A biomedical complication of addiction or co-occurring biomedical condition that requires active nursing or medical monitoring but does not require the resources of an acute care hospital b. Continued alcohol or drug use places the adolescent at imminent risk of serious damage to physical health because of a biomedical condition (i.e.. brittle diabetes, pregnancy or HIV), which requires active nursing or medical monitoring 8

9 Dimensional Admission Criteria: Level III.7 DIMENSION 3: Emotional, Behavioral, or Cognitive Conditions and Complications 1. The adolescent s status features one or more of the following: a. Dangerousness/Lethality-The adolescent is at moderate (and unpredictable) risk of imminent harm (self or others) and needs highintensity 24-hour monitoring or treatment, or secure containment, for safety. b. Interference with Recovery Efforts- Severe interference and distraction with recovery efforts requires highintensity residential treatment to stabilize emotional or behavioral problems and support engagement. DIMENSION 3: (cont d) c. Social Functioning- Significant impairments with severe symptoms (poor impulse control, disorganization, etc) that seriously impair functioning in family, social, school or work settings (repeatedly running away, seriously aggressive or disruptive behaviors) and cannot be managed at a less intensive level of care. d. The adolescent evidences moderate to severe difficulties with activities of daily living and requires 24-hour supervision and high-intensity staff assistance. e. The adolescent s history (combined with the present situation) predicts destabilization without high-intensity residential treatment. 9

10 Dimensional Admission Criteria: Level III.7 DIMENSION 4: Readiness to change 1. The adolescent s status is characterized by one of the following: a. The adolescent has not related his or her problems to substance use or has not accepted the need for change b. The adolescent has not demonstrated sufficient readiness to change and thus needs intensive motivating strategies, activities and processes available only in a 24-hour high-intensity structured setting 10

11 Dimensional Admission Criteria: Level III.7 DIMENSION 5: Relapse, Continued Use or Continued Problem Potential DIMENSION 6: Recovery Environment 1. The adolescent s status is characterized by one of the following: a. The adolescent is unable to interrupt a high severity or high frequency pattern of use with imminent severe risk of dangerous consequences without highintensity 24-hour interventions b. The modality of treatment requires this level of care (i.e., agonist or antagonist therapy, monitoring, case management and documentation needed to arrange alternative level of care or resource) 1. The adolescent s status is characterized by one of the following: a. The adolescent s living environment is dangerous to his or her recovery, and he or she requires residential treatment to promote recovery goals or for protection b. The adolescent requires this LOC to help him or her establish a successful transition to a less intensive level of care. 11

12 All of the following must be met: Managing Care: PRTF Admission Criteria Are their symptoms consistent with a DSM-IV-TR (Axis I-V) diagnosis that requires, and can reasonably be expected to respond to, therapeutic intervention? Yes No 12

13 All of the following must be met: Managing Care: PRTF Admission Criteria The child/adolescent 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. Yes No 13

14 All of the following must be met: Managing Care: PRTF Admission Criteria The child/adolescent demonstrates a capacity to respond favorably to rehabilitative counseling and training in areas such as problem solving, life skills development, and medication compliance training. Yes No 14

15 All of the following must be met: Managing Care: PRTF Admission Criteria The child/adolescent has a history of multiple hospitalizations or other treatment episodes and/or recent inpatient stay with a history of poor treatment adherence or outcome. Yes No 15

16 All of the following must be met: Managing Care: PRTF Admission Criteria Less restrictive or intensive levels of treatment have been tried and were unsuccessful, or are not appropriate to meet the individual s needs Yes No 16

17 All of the following must be met: Managing Care: PRTF Admission Criteria The family situation and functioning levels are such that the child/adolescent cannot currently remain in the home environment and receive community-based treatment Yes No 17

18 Don t assume that if a patient relapses (substance abuse) after treatment at a lower level of care that PRTF is needed. Managing Care: PRTF Admission Criteria Relapse is an expected part of the recovery process! 18

19 Managing Care: PRTF Admission Criteria (Substance Abuse) Lapse vs. Relapse LAPSE RELAPSE Impulsive Short Duration They feel guilty Small amount of use Relatively low consequences They want to stop using Planned Long period of use High defensiveness Large amount of use Relatively high consequences They aren t sure if they want to stop using 19

20 The following questions should be asked: What precipitated this admission? What other treatment episodes has this patient had? What levels of care? What worked? What needs to be put in place now? Is the patient motivated for change? Is the family /care givers supportive? If not, why not? What can be done to improve this support? What symptoms are they exhibiting that meet criteria for this level of care? PRTF Admission Criteria Key Questions 20

21 Areas to Focus On The child/adolescent has current or past behaviors that indicate the need for PRTF as evidenced by suicidal or homicidal ideation, physical aggression toward others, self-injurious behavior, seriously risky behavior (running away, sexual aggression, serial unprotected sex with multiple partners, or substance use). For each authorization, this admission criteria must be met and the treatment plan continually evaluated to determine efficacy of the treatment plan, overall safety of the patient, and appropriateness of this level of care! 21

22 All of the following must be met: Managing Care: PRTF Continued Stay Criteria The child/adolescent's condition continues to meet admission criteria at this level of care. Yes No 22

23 All of the following must be met: Managing Care: PRTF Continued Stay Criteria The child/adolescent s treatment does not require a more intensive level of care, and no less intensive level of care would be appropriate Yes No 23

24 All of the following must be met: Managing Care: PRTF Continued Stay Criteria Treatment planning is individualized and appropriate to the recipient s changing condition with realistic and specific goals and objectives stated. Treatment planning should include active family or other support systems involvement, along with social, occupational and interpersonal assessment unless contraindicated. The expected benefits from all relevant treatment modalities are documented. The treatment plan has been implemented and updated, with consideration of all applicable and appropriate treatment modalities. Yes No 24

25 All of the following must be met: Managing Care: PRTF Continued Stay Criteria All services and treatment are carefully structured to achieve optimum results in the most time efficient manner possible consistent with sound clinical practice. Yes No 25

26 All of the following must be met: Managing Care: PRTF Continued Stay Criteria If treatment progress is not evident, then there is documentation of treatment plan adjustments to address such lack of progress Yes No 26

27 All of the following must be met: Managing Care: PRTF Continued Stay Criteria Care is rendered in a clinically appropriate manner and focused on the child/adolescent s behavioral and functional outcomes Yes No 27

28 All of the following must be met: Managing Care: PRTF Continued Stay Criteria An individualized discharge plan has been developed which includes specific realistic, objective and measurable discharge criteria and plans for appropriate follow-up care. A timeline for expected implementation and completion is in place but discharge criteria have not yet been met. Yes No 28

29 All of the following must be met: Managing Care: PRTF Continued Stay Criteria Child/adolescent is actively participating in treatment to the extent possible consistent with his/her condition, or there are active efforts being made that can reasonably be expected to lead to the child/adolescent s engagement in treatment. Yes No 29

30 All of the following must be met: Managing Care: PRTF Continued Stay Criteria Unless contraindicated, family, guardian, and/or custodian is actively involved in the treatment as required by the treatment plan, or there are active efforts being made and documented to involve them. Yes No 30

31 All of the following must be met: Managing Care: PRTF Continued Stay Criteria When medically necessary, appropriate psychopharmacological intervention has been prescribed and/or evaluated. Yes No 31

32 All of the following must be met: Managing Care: PRTF Continued Stay Criteria There is documented active discharge planning from the beginning of treatment Yes No 32

33 All of the following must be met: Managing Care: PRTF Continued Stay Criteria There is a documented active attempt at coordination of care with relevant outpatient providers when appropriate Yes No 33

34 Managing Care: PRTF Continued Stay Criteria Children/adolescents have difficulty maintaining treatment gains if the family/supports haven t done their work too! Healthcare Providers Family/Supports Child/Adolescent 34

35 Managing Care: PRTF Continued Stay Criteria If treatment progress is not evident, then is there documentation of treatment plan adjustments to address such lack of progress (i.e.. Is the family/support system involved? If not why not? Have attempts to engage them been made? What happened? What now?) An individualized discharge plan has been developed with includes specific realistic, objective and measurable discharge criteria and plans for appropriate follow-up care. A timeline for expected implementation and completion is in place but discharge criteria have not yet been met. DISCHARGE PLANNING is part of treatment planning, not a discreet activity 35

36 PRTF Understanding Discharge The consumer 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 What is the estimated discharge date and plan? 36

37 PRTF: Discharge Criteria BOTH of the following must be met for Discharge: The child or adolescent can be safely treated at an alternative level of care An individualized discharge plan with appropriate, realistic and timely follow-up care is in place 37

38 PRTF Understanding Discharge In addition at least one of the following must also be met: The treatment plan goals and objectives have been substantially met or a safe, continuing care program has been put in place at an alternate level of care. Admission criteria is no longer met for this level of care and the patient can safely be treated in a less restrictive, intense environment. The support system is competent but non-participatory in treatment or in following the program rules, to such a degree that treatment has been rendered ineffective or unsafe. Consent for treatment is withdrawn, and the child/adolescent, parent, or guardian has the capacity to make an informed decision AND the patient does not meet criteria for inpatient admission. The child or adolescent is not making progress toward treatment goals despite persistent efforts to engage him or her, and there is no reasonable expectation of progress at this level of care; nor is the level of care required to maintain the current level of function. 38

39 Question and Answer Session Presented by: Lynnette Gordon, LPC, LCAS UM director Eastpointe LME/MCO

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