Members must meet medical necessity criteria for a particular LOC. Medically necessary services are those services that:

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1 BEACON HEALTH STRATEGIES, LLC. / MASSACHUSETTS LEVEL OF CARE CRITERIA LEVEL OF CARE CRITERIA Beacon s Level of Care (LOC) criteria were developed from the comparison of national, scientific and evidence based criteria sets, including but not limited to those publicly disseminated by the American Medical Association (AMA), American Psychiatric Association (APA), Substance Abuse and Mental Health Services Administration (SAMHSA), and the American Society of Addiction Medicine (ASAM). Beacon s LOC criteria, are reviewed and updated, at least annually, and as needed when new treatment applications and technologies are adopted as generally accepted medical practice. Members must meet medical necessity criteria for a particular LOC. Medically necessary services are those services that: 1. Are calculated to prevent, diagnose, prevent the worsening of, alleviate, correct or cure conditions that endanger life, cause suffering or pain, cause physical deformity or malfunction, threaten to cause or aggravate a disability, or result in illness or infirmity 2. Are in accordance with professionally accepted clinical guidelines and standards of practice in behavioral healthcare. 3. Are furnished in the most appropriate and least restrictive setting in which services can be safely provided. 4. Are not primarily for the convenience of the patient or the physician. 5. Are reasonably expected to provide benefit. Beacon uses its LOC criteria as guidelines, not absolute standards, and considers them in conjunction with other indications of a member s needs, strengths, and treatment history in determining the best placement for a member. Beacon s LOC criteria are applied to determine appropriate care for all members. In general, members will only be certified if they meet the specific medical necessity criteria for a particular LOC. However, the individual s needs and characteristics of the local service delivery system are taken into consideration. In addition to meeting Level of Care Criteria; services must be included in the member s benefit to be considered for coverage. Overview SECTION I: INPATIENT BEHAVIORAL HEALTH This chapter contains information on LOC criteria and service descriptions for inpatient behavioral health (BH) treatment including: A. Acute Inpatient Psychiatric Services B. Inpatient Substance Use Disorder Services - Medically Managed (Level IV Detoxification) C. Transfer from Medical to Acute Inpatient Psychiatric Services D. Observation Beds 1

2 A. Acute Inpatient Psychiatric Services Acute inpatient psychiatric service is the most intensive level of psychiatric treatment, and is used to stabilize individuals with an acute worsening, destabilization, or sudden onset psychiatric condition of short, severe duration. A structured treatment milieu and 24-hour medical and skilled nursing care is fundamental to inpatient treatment. Daily contact between the member and physician is required. Behavioral health providers may also have physical and mechanical restraint, isolation and locked units available as additional resources. Admission Criteria Continued Stay Criteria Discharge Criteria Must meet all criteria # 1-4; For Eating Disorders, # 5 or 6 must also be met: 1. DSM or corresponding ICD diagnosis is present. 2. Member s psychiatric condition must require 24-hour medical/psychiatric and nursing services and/or must be of such intensity that needed services can only be provided by acute hospital care. 3. Inpatient services in an acute care hospital must be expected to significantly improve the member s psychiatric condition within a reasonable period of time so that acute, short-term 24-hour inpatient medical/psychiatric and nursing services will no longer be needed. 4. One of the following must also be present: a. Indication of actual and/or potential danger to self or others, such as serious suicidal ideation with plan especially with means available and a prior history of significant suicide attempts or homicidal ideation with documented history of violence; b. Suicidal ideation accompanied by severely depressed mood, significant losses and/or continuing intent to hurt self; c. Homicidal ideation with indication of actual or potential danger to others; d. Command hallucinations to harm self or others; e. Persecutory delusions with potential violence to self or others; f. Loss of impulse control resulting in life threatening behavior, significant weight loss within the past three months, or self mutilation that could lead to permanent disability; g. Indication of actual or potential danger to property evidenced by credible threats of destructive acts or Criteria #1-9 must be met; For Eating Disorders, criterion #10 must be met: 1. Member continues to meet admission criteria; 2. Another less restrictive LOC would not be adequate to provide needed containment and administer care. 3. Member is experiencing symptoms of such intensity that if discharged, s/he would likely need rapid rehospitalization; 4. Treatment is still necessary to reduce symptoms and improve functioning so member may be treated in a less restrictive LOC. 5. There is evidence of progress towards resolution of the symptoms causing a barrier to treatment continuing in a less restrictive LOC; 6. Medication assessment has been completed when appropriate and medication trials have been initiated or ruled out. 7. Family/guardian/caregiver is participating in treatment where appropriate. 8. There is documentation of coordination of treatment with state or other community agencies, if involved. 9. Coordination of care and active 2 Criteria #1, 2, 3, or 4 are suitable; criteria # 5 and 6 are recommended, but optional. For Eating Disorders, criteria #7-9 must be met: 1. Member no longer meets admission criteria and/or meets criteria for another LOC, either more or less intensive. 2. Member or parent/guardian withdraws consent for treatment and member does not meet criteria for involuntary/ mandated treatment. 3. Member does not appear to be participating in the treatment plan. 4. Member is not making progress toward goals, nor is there expectation of any progress. 5. Member s individual treatment plan and goals have been met. 6. Member s support system is aware and in agreement with the aftercare treatment plan. For Eating Disorders: 7. Member has reached at least 75% healthy body weight and has gained enough weight to achieve medical stability (e. g., vital signs, electrolytes, and electrocardiogram are stable). 8. No re-feeding is necessary 9. All other psychiatric disorders are stable.

3 Admission Criteria Continued Stay Criteria Discharge Criteria documented recent history of violent or dangerous and destructive acts that may injure self or others; h. Individual is impaired on the basis of their primary psychiatric illness to the degree that s/he manifests major disability in basic activities of daily living or social, interpersonal, occupational and/or educational functioning and is not responsive to treatment and/or management efforts at a less intensive level of care; i. Individual has substance use disorder/dependence and need for treatment and services to ensure sobriety during stabilization of psychiatric condition; or j. Evidence of severe disorders of cognition, memory, or judgment not associated with a primary diagnosis of dementia or other cognitive disorder and family/community support cannot be relied upon to provide essential care. For Eating Disorders:* 5. Member has psychiatric, behavioral and general medical factors (such as a rapid or persistent decline in oral intake and significant decline in weight). 6. Member has had a rapid life threatening and volitional weight (i.e. not thought to be the result of medical illness) loss (Body Mass Index < 16) or below 75% of estimated healthy body weight that required treatment in an acute medical setting for one of the following: a. Marked physiological lability, e.g. significant postural hypotension, bradycardia, CHF, cardiac arrhythmia; b. Change in mental status; c. Body temperature below 96 degrees; d. Severe metabolic abnormality with anemia, hypokalemia, or other metabolic derangement; e. Acute gastrointestinal dysfunction such as esophageal tear from vomiting, mega colon or colonic damage from self-administered enemas; or f. Member has been uncooperative with treatment and/or is only able to cooperative in a highly structured, controlled setting that can provide one or all of the following: Needed supervision during and after meals and/or required special feeding discharge planning are ongoing, with goal of transitioning the member to a less intensive LOC. For Eating Disorders: 10. No appreciable weight gain (<2lbs/wk) and/or unstable medical sequelae or refeeding complication. 3

4 Admission Criteria Continued Stay Criteria Discharge Criteria Needed supervision during and after all meals and during use of bathroom *Exception to the above criteria may be made for early intervention with newly diagnosed adolescent eating disorder admission requests For Acute Inpatient Mental Health Services - High Intensity** For Acute Inpatient Mental Health Services - High Intensity** For Acute Inpatient Mental Health Services - High Intensity** In addition to the criteria for general Acute Inpatient Psychiatric Services, the following is necessary: Member s current presentation represents a threat of harm to self or others which is not likely to be safely managed on a general inpatient psychiatric unit as evidenced by; Member consistently requires a level of close monitoring or intervention by staff beyond 1:1 observation and the usual capacity of a general inpatient psychiatric unit to maintain safety; Member s treatment requires staff with specific training and skills to treat and contain atypical aggressive, assaultive behavior beyond the abilities of typical general inpatient psychiatric unit staff; or Member s treatment and maintenance of safety require a highly-structured clinical program and environment including single rooms, limited census, enhanced staffing and increased observation. Additionally; at least one of the following criteria (1-4) must be met as further evidence of current danger to self or others requiring more intensive observation and intervention than can be provided by a general inpatient psychiatric unit: 1. Member has an established history of significant treatmentresistant assaultive behavior to self and/or others; Must meet ALL continued stay criteria for Acute Inpatient Psychiatric Services as well as the following: 1. Member s condition continues to meet admission criteria for Acute High Intensity Inpatient Mental Health Services requiring specialized milieu and increased observation and staffing levels 2. Acute treatment interventions have not been exhausted, and; 3. No other less intensive level of care would be adequate. ANY of the following criteria (1-3) is sufficient for discharge from Acute Inpatient Mental Health High Intensity: 1. Member no longer meets continuing stay criteria for Acute High Intensity Inpatient Mental Health Services requiring specialized milieu and increased observation and staffing levels but does meet admission criteria for general Acute Inpatient Psychiatric Services or another LOC, either more or less intensive.; 2. Treatment plan goals and objectives have been substantially met and/or a safe, continuing care program can be arranged and deployed at a less intensive level of care, OR; Member is not making progress toward treatment goals and there is no reasonable expectation of progress at this level of care. The need for high intensity of services is the result of a chronic condition, and member requires transfer to a long term care setting for 4

5 Admission Criteria Continued Stay Criteria Discharge Criteria 2. Member has recent history of behaviors that were not successfully or safely managed on a general inpatient psychiatric unit; 3. Member is actively engaged in significant dangerous behavior which has not responded to usual interventions at a less intensive level of care, or; 4. Member has a significant history of dangerous sexualized behavior including being a registered Level III Sex Offender or person designated as a Sexually Dangerous Person. Exclusion Criteria: 1. Medical condition that requires a medical/surgical setting for treatment, regardless of the psychiatric presentation; 2. Medical co-morbidities unable to be safely managed in this specialty setting; 3. Behavioral dyscontrol in the context of traumatic brain injury, intellectual disability, pervasive developmental disorder, dementia, or other medical condition without indication of acute Axis I or II diagnosis; 4. Current legal charges including murder, aggravated assault, and rape, and eligible for treatment in a specialized forensic program; or Member can be safely treated in a general psychiatric inpatient unit. **Acute High Intensity Inpatient Services provides psychiatric services of a higher level of intensity than can be provided by a general psychiatric inpatient psychiatric unit. This service provides a level of security beyond the capacity of a general psychiatric inpatient unit to assure the safety of the member, other patients, and staff. In addition to the usual twenty-four hour skilled nursing care, daily medical care, structured treatment milieu, multidisciplinary assessments and multimodal 5 ongoing treatment.

6 Admission Criteria Continued Stay Criteria Discharge Criteria interventions, this service provides single rooms, limited census, enhanced staffing, and increased capacity for observation and intervention by staff specifically trained to treat and contain atypical aggressive, assaultive and dangerous behavior occurring in the context of an acute psychiatric presentation. The goal of this specialized service is acute stabilization and treatment of the member s presenting condition, including dangerous behavior, so that the member can transition to a general inpatient psychiatric unit or another less intensive level of care. In addition to the above criteria; Acute High Intensity Inpatient Services would not be authorized exclusively in response to general psychiatric inpatient bed availability. 6

7 B. Inpatient Substance Use Disorder Services - Medically Managed (Level IV Detoxification) Level IV detoxification is a 24-hour medically-directed evaluation program, providing care and treatment to members with psychoactive substance use disorders in a medically managed inpatient setting. All resources of a general hospital are available including life-support care and psychiatric treatment. This service provides 24-hour physician availability. Daily contact between the member and physician is required. Primary nursing care and observation is available 24 hours per day and counseling services are readily available. A multidisciplinary team of addiction professionals and addiction-certified clinicians are utilized to provide treatment services. Although the treatment is specific to substance use disorders, the multidisciplinary team and available support services allow for the combined treatment of coexisting acute biomedical and emotional/behavioral conditions. Admission Criteria Continued Stay Criteria Discharge Criteria Criteria # 1 and 2, and any one of # 3 8 must be met: 1. DSM or corresponding ICD substance use disorder diagnosis of physical dependence 2. Member is at risk for complicated withdrawal symptoms in the absence of medical management. 3. There is a concomitant medical condition requiring medical/nursing care on a 24 hours/day basis; (e.g., delirium tremens [DTs], recent seizure, known seizure disorder, h/o seizures or DTs when withdrawing from similar amounts of similar substances, h/o serious head injury or unstable hypertension). 4. For sedative hypnotics: Member s recent pattern of daily substance use poses risk of severe withdrawal syndrome; or Member has had or is experiencing seizures, severe or persistent hallucinations and/or DTs. 5. For opiates: Member is experiencing severe opiate withdrawal that cannot be stabilized or managed in a less intensive level of care (LOC). 6. For stimulants: Intoxification or withdrawal All of the following criteria must be met: 1. Member continues to meet admission criteria; 2. Another less restrictive LOC would not be adequate to provide needed containment and administer care. 3. Member is experiencing symptoms of such intensity that if discharged, s/he would likely need rapid re-hospitalization; 4. Treatment is still necessary to reduce symptoms and improve functioning so member may be treated in a less restrictive LOC. 5. There is evidence of progress towards resolution of the symptoms causing a barrier to treatment continuing in a less restrictive LOC; 6. Family/guardian/caregiver is participating in treatment as clinically indicated and where appropriate or engagement efforts are underway. 7. Appropriate use of medications at least once per 24 hours to modify withdrawal symptoms. 8. Alcohol: CIWA score is equal to or > 15 or irregular vital signs are evident (T>100, BP 160 systolic/100 diastolic, HR>=110). 9. Coordination of care and active discharge planning are ongoing, with goal of 7 Criteria # 1, 2, or 3 are suitable; criteria # 4 and 5 are recommended, but optional: 1. Member no longer meets admission criteria and/or meets criteria for another LOC, either more or less intensive. 2. Member or parent/guardian withdraws consent for treatment and member does not meet criteria for involuntary/mandated treatment. 3. CIWA score is equal to or < Member s individual treatment plan and goals have been met. 5. The member s support system is in agreement with the aftercare treatment plan.

8 signs/symptoms require either acute medical and/or psychiatric monitoring and cannot be stabilized in a less intensive LOC. 7. High risk pregnancy. 8. Alcohol: CIWA score is equal to or > 15 and irregular vital signs are evident (T>101, BP 200/100, HR >=110 or member has elevated CIWA score in the absence of elevated BP or HR and is prescribed a beta blocker or other antihypertensive medication. transitioning the member to a less intensive LOC. C. Transfer from Medical to Acute Inpatient Psychiatric Services. Transfer from medical to inpatient psychiatric services is transfer from an inpatient medical unit to an acute inpatient psychiatric unit after a member has completed medically necessary treatment and is medically stable to be transferred. For members whose medical problems are fully treated/stabilized, the criteria for transfer from an acute medical bed to an acute inpatient psychiatric bed are the same as those for admission to inpatient acute psychiatric treatment. Admission Criteria Criteria # 1 must be met: 1. DSM or corresponding ICD diagnosis must be present; AND A. Adequate medical evaluation (and appropriate treatment) to exclude delirium as an explanation of patient s symptoms. AND Meets criteria for Acute Inpatient Psychiatric Services, as listed above Note about management of delirium: Delirium is often confused with dementia, depression or primary psychotic disorder. Delirium, an acute confusional state with fluctuating levels of consciousness, is a medical emergency, requiring metabolic and neurological evaluation. Most inpatient psychiatric units are not resourced to adequately diagnose, treat and manage medical emergencies. Therefore, it is inappropriate and unsafe for members with delirium to be treated in psychiatric settings. The appropriate role for Beacon clinicians and physician reviewers is to assess the residual psychiatric symptoms of these members, AFTER the delirium is diagnosed and the medical precipitant treated and stabilized on a medical unit. We then assess each member in accordance with the above guidelines. 8

9 D. Observation Beds (OBS) Observation (OBS) beds allow time for extended assessment or observation and are utilized when additional information about the member s condition is likely to result in a more appropriate referral to a less intensive level of care (e.g., suicidal person who is intoxicated may clear in hours). This level of care (LOC) is generally used for duration of 24 hours or less though may be extended as required for a maximum of 72 hours. Admission Criteria Continued Stay Criteria Discharge Criteria All of the following criteria must be met: 1. A DSM or corresponding ICD diagnosis is present. 2. Member must also have at least one of the following symptoms: Indication of actual or potential danger to self or others; Loss of impulse control leading to life threatening behavior; or Substance intoxication with suicidal/homicidal ideation or inability to care for self 3. Member has the potential to stabilize within 24 hours, at which time diversionary treatment may be initiated. 4. Member is willing to participate in treatment voluntarily. All of the following criteria must be met: 1. Member continues to meet admission criteria; 2. Another less restrictive LOC would not be adequate to provide needed containment and administer care. 3. Member is experiencing symptoms of such intensity that if discharged, s/he would likely need rapid re-hospitalization; 4. Treatment is still necessary to reduce symptoms and improve functioning so member may be treated in a less restrictive LOC. 5. There is evidence of progress towards resolution of the symptoms causing a barrier to treatment continuing in a less restrictive LOC; 6. Medication assessment has been completed when appropriate and medication trials have been initiated or ruled out. 7. Family/guardian/caregiver is participating in treatment as clinically indicated, or engagement efforts are underway. 8. Coordination of care and active discharge plan include goal of either transitioning the member to a less intensive LOC within hours of admission or transferring the member to a higher LOC. Criteria #1, 2, 3, or 4 are suitable: criteria # 5 and 6 are recommended, but optional: 1. Member no longer meets admission criteria and/or meets criteria for another LOC, either more or less intensive. 2. Member or parent/guardian withdraws consent for treatment and member does not meet criteria for involuntary/mandated treatment. 3. Member does not appear to be participating in the treatment plan 4. Member is not making progress toward goals, nor is there expectation of any progress. 5. Member s individual treatment plan and goals have been met. 6. Member s support system is in agreement with the aftercare treatment plan. 9

10 SECTION II: 24 HOURS DIVERSIONARY SERVICES Overview Diversionary services are those mental health and substance use disorder services that are provided as clinically appropriate alternatives to inpatient behavioral health services, or to support a member in returning to the community following a 24-hour acute placement; or to provide intensive support to maintain functioning in the community. There are two categories of diversionary services, those provided in a 24-hour facility, and those which are provided in a non- 24-hour setting or facility. This chapter contains service descriptions and level of care criteria for the following 24-hour diversionary services: A. Adult Crisis Stabilization Unit (CSU) B. Community Based Acute Treatment (CBAT) C. Clinical Stabilization Services (CSS) for Substance Use Disorders (Level III.5) D. Acute Treatment Services (ATS) for Substance Use Disorders Medically Monitored (Level III Detoxification) E. Adolescent Acute Inpatient Detoxification and Rehabilitation for Substance Use Disorders F. Transitional Care Unit (TCU) G. Dual Diagnosis Acute Treatment (DDAT) 10

11 A. Adult Crisis Stabilization Unit (CSU) / Community Crisis Stabilization (CCS) Crisis stabilization beds provide short-term psychiatric treatment within structured, community-based therapeutic environments. Each program provides continuous 24-hour observation and supervision for members who do not require the intensive medical treatment of hospital care. The purpose of this level of care (LOC) is to stabilize a member who is in crisis and to prevent an unnecessary hospital admission. Crisis stabilization beds may be located in a hospital or a community-based setting. Immediate and intense involvement of family and community support for post-discharge follow-up is an important aspect of this LOC. In general, episodes appropriate for crisis stabilization are brief. In most instances, two to three days are sufficient to arrest the escalating problems, resolve the crisis, access appropriate community supports and return the member to a less restrictive LOC. Crisis stabilization units are ideally suited for the member with a known diagnosis who is decompensating because of treatment non-adherence, or because of the dynamics of the psychiatric disorder (e.g., inherently unstable conditions such as schizophrenia or bipolar disorder, or certain personality disorders). For such members, decompensation may be halted through placement in a 24-hour safe bed. Admission Criteria Continued Stay Criteria Discharge Criteria All of the following criteria must be met: 1. DSM or corresponding ICD diagnosis 2. The psychiatric condition or emotional disturbance in response to a situational crisis poses a current threat to the member s ability to function in her/his current setting. 3. The duration of the exacerbation of the psychiatric or emotional disturbance is expected to be brief and temporary. 4. All evidence points to the onset of an acute destabilization of behavior or function, but there is insufficient information concerning baseline functioning and family/community support to warrant inpatient psychiatric care. 5. Member (and guardian, when appropriate) is willing to participate in treatment voluntarily. 6. Member s discharge placement must be identified and available upon admission. All of the following criteria must be met: 1. Member continues to meet admission criteria; 2. Another less restrictive LOC would not be adequate to provide needed containment and administer care. 3. Member is experiencing symptoms of such intensity that if discharged, s/he would likely need a more restrictive LOC; 4. Treatment is still necessary to reduce symptoms and improve functioning so member may be treated in a less restrictive LOC. 5. There is evidence of progress towards resolution of the symptoms causing a barrier to treatment continuing in a less restrictive LOC; 6. Member progress is monitored regularly, and the treatment plan modified, if the member is not making substantial progress toward a set of clearly defined and measurable goals. 7. Medication assessment has been completed when appropriate and medication trials have been initiated or ruled out. 8. Family/guardian/caregiver are participating in treatment as clinically indicated and appropriate, or engagement efforts are underway. 9. Coordination of care and active discharge planning are ongoing, with goal of transitioning the member to a less intensive LOC. 11 Criteria # 1, 2, 3, or 4 are suitable; criteria # 5 and 6 are recommended, but optional: 1. Member no longer meets admission criteria and/or meets criteria for another LOC, either more or less intensive. 2. Member or parent/guardian withdraws consent for treatment. 3. Member does not appear to be participating in treatment plan. 4. Member is not making progress toward goals, nor is there expectation of any progress. 5. Member s individual crisis stabilization plan and goals have been met. 6. Member s support system is in agreement with the aftercare treatment plan.

12 B. Community Based Acute Treatment (CBAT) CBATs are 24-hour therapeutically planned group living programs. In addition to the milieu, the program provides individualized therapeutic treatment. CBAT is not equivalent to acute, intermediate or long-term hospital care, rather its design is to maintain the member in the least restrictive environment to allow for stabilization and integration. Consultations and psychological testing, as well as routine medical care, are included in the per diem rate. CBATs serve members who have sufficient potential to respond to active treatment, need a protected and structured environment and for whom outpatient, partial hospitalization or acute hospital inpatient treatments are not appropriate. CBAT is planned according to each member s needs and is generally completed in 1 14 days. Realistic discharge goals should be set at admission, and full participation in treatment by the member and his or her family members, as well as community-based treators is expected when appropriate. Admission Criteria Continued Stay Criteria Discharge Criteria Criteria #1 7 must be met for all; For Eating Disorders, criteria # 8-11 must also be met: 1. DSM or corresponding ICD diagnosis and must have mood, thought, or behavior disorder of such severity that there would be a danger to self or others if treated at a less restrictive level of care (LOC.) 2. Member has sufficient cognitive capacity to respond to active acute and time limited psychological treatment and intervention. 3. Member has only poor to fair motivation and/or insight and community supports are inadequate to support recovery. 4. Member requires a time limited period for stabilization and community re-integration. 5. When appropriate, family/guardian/ caregiver agrees to participate actively in treatment as a condition of admission. 6. Member s behavior or symptoms, as evidenced by the initial assessment and treatment plan, are likely to respond to or are responding to active treatment. 7. Admission request is not primarily based on a lack of intermediate or long term residential placement availability. Criteria # 1 9 must be met for all; For Eating Disorders criteria # 10 and 11 must be met: a. Member continues to meet admission criteria; b. Another less restrictive LOC would not be adequate to provide needed containment and administer care. c. Member is experiencing symptoms of such intensity that if discharged, s/he would likely be readmitted; d. Treatment is still necessary to reduce symptoms and improve functioning so member may be treated in a less restrictive LOC. e. There is evidence of progress towards resolution of the symptoms causing a barrier to treatment continuing in a less restrictive LOC; f. Medication assessment has been completed when appropriate and medication trials have been initiated or ruled out. g. Member s progress is monitored regularly and the treatment plan modified, if the member is not making progress toward a set of clearly defined and measurable goals. 12 Criteria # 1, 2, 3, or 4 are suitable; criteria # 5 and 6 are recommended, but optional; For Eating Disorders, criterion # 7 must be met: 1. Member no longer meets admission criteria and/or meets criteria for another LOC, more or less intensive. 2. Member or parent/guardian withdraws consent for treatment and the member does not meet criteria for involuntary/mandated treatment. 3. Member does not appear to be participating in the treatment plan. 4. Member is not making progress toward goals, nor is there expectation of any progress. 5. Member s individual treatment plan and goals have been met. 6. Member s support system is in agreement with the aftercare treatment plan. For Eating Disorders 7. Member has gained weight, is in better control of weight reducing behaviors/actions, and can now be safely and effectively managed in a less intensive LOC.

13 Admission Criteria Continued Stay Criteria Discharge Criteria For Eating Disorders: 8. Member is medically stable and does not require IV fluids, tube feedings or daily lab tests. 9. Member has had a recent significant weight loss and cannot be stabilized in a less restrictive LOC. 10. Member needs direst supervision at all meals and may require bathroom supervision for a time period after meals. 11. The member is unable to control obsessive thoughts or to reduce negative behaviors (e. g., restrictive eating, purging, laxative or diet pill abuse, and/or excessive exercising) in a less restrictive environment. h. Family/guardian/caregiver is participating in treatment as clinically indicated and appropriate or engagement is underway. i. There must be evidence of coordination of care and active discharge planning to: a. transition the member to a less intensive LOC; b. operationalize how treatment gains will be transferred to subsequent LOC. For Eating Disorders: j. Member continues to need supervision for most if not all meals and/or use of bathroom after meals. k. Member has had no appreciable weight gain since admission. 13

14 C. Clinical Stabilization Services (CSS) for Substance Use Disorders (III.5) CSS programs are 24-hour, therapeutically planned treatment and learning environments for adults 18 and older, with a primary substance use disorder. The goal of CSS is to stabilize members in early recovery and to increase their retention in treatment. In addition to group treatment, CSS provides individual treatment, and maintains the least restrictive environment that allows for normalization. CSS is a less intensive level of care (LOC) than both ATS and Level IV detoxification. Members placed at this LOC need further assessment, stabilization and short term intensive substance use residential treatment. CSS serves adult substance using members with sufficient potential to respond to active treatment, who need a protected and structured environment, and for whom outpatient, partial hospital or inpatient treatments are not appropriate. CSS can usually be completed in less than 30 days, provided realistic dischargeoriented goals are set at admission, and there is full participation by the member and family, where appropriate. Admission Criteria Continued Stay Criteria Discharge Criteria All of the following criteria must be met: 1. DSM or corresponding ICD substance use disorder diagnosis. 2. Sufficient cognitive capacity and mental health stability to safely participate in, respond to, and benefit from active substance use treatment. 3. Minimal risk for severe withdrawal syndrome as determined by initial bio-psychosocial assessment or CIWA evaluation. 4. Member presents with significant social and psychosocial problems. 5. Member s recovery environment is compromised warranting a structured residential treatment to monitor recovery. 6. Member s biomedical condition is stable enough to be managed in a structured residential setting. 7. Co-morbid psychiatric conditions and medication status are sufficiently stable to be managed in a structured residential setting. 8. Must meet A and either B or C a. A less intensive/restrictive level of care is insufficient for effective treatment to continue. and b. This is the first episode of addictions All of the following criteria must be met: 1. Member continues to meet admission criteria; 2. Another less restrictive LOC would not be adequate to provide needed containment and administer care. 3. Member is experiencing symptoms of such intensity that if discharged, s/he would likely require a more restrictive LOC; 4. Treatment is still necessary to reduce symptoms and improve functioning so member may be treated in a less restrictive LOC. 5. There is evidence of progress towards resolution of the symptoms causing a barrier to treatment continuing in a less restrictive LOC; 14 Criteria # 1, 2, or 3 are suitable: 1. Member no longer meets admission criteria and/or meets criteria for another LOC, either more or less intensive. 2. Member or parent/guardian withdraws consent for treatment 3. Member does not appear to be participating in treatment plan.

15 Admission Criteria Continued Stay Criteria Discharge Criteria treatment or c. There is an indication of progression through stages of change as evidenced by a specific recent event that has significantly impacted motivation, (e.g.: a near-lethal overdose, family issue, seizure or other medical issue, change in external/legal motivators, first time seeking services without external motivators, etc.,) sufficient to suggest increased likelihood of benefit from this service from previous treatment episodes. 9. Member is considered to be at risk of serious, imminent physical harm to self or others resulting from their continued use of substances. 10. Admission request is not primarily based on the member s current lack of placement or housing. 15

16 D. Acute Treatment Services (ATS) for Substance Use Disorders Medically Monitored (Level III Detoxification) ATS provides a planned regimen of 24-hour, medically monitored evaluation, care and treatment in a licensed acute care setting, for members with a substance use disorder diagnosis of physical dependence. Typically, physician involvement includes 24-hour consultation availability, daily interaction with specified members, and overall monitoring of medical care. Twenty-four hour nursing care and observation are provided to members. Staff trained in addiction treatment offer daily counseling services. This level of care (LOC) does not require the full resources of a general hospital, life-support equipment or psychiatric services. Appropriate members for this LOC are at risk for severe withdrawal syndrome, require 24-hour medically monitored nursing care and observation, do not require the medical and clinical intensity of a hospital based acute detoxification unit, and cannot be effectively treated in a less intensive LOC. Referrals for ATS can originate from self-referral, physicians, emergency rooms, state agencies or other ancillary programs. (See continuation of level of care criteria, next page.) Admission Criteria Continued Stay Criteria Discharge Criteria Criteria # 1, 2, and 3 must be met and any one of criteria # 4-8 must also be met: 1. DSM or corresponding ICD substance use disorder diagnosis of physical dependence. 2. Detox requires medical monitoring and 24 hour inpatient nursing services. 3. Member: Is experiencing signs and symptoms of moderate withdrawal; or There is a history of/or evidence that severe withdrawal is imminent when substance use is discontinued; or Past attempts to stop substance use on member s own have led to significant withdrawal symptoms. 4. For opiates: Member has used drugs daily for more than 2 weeks; and Member has a history of an inability to complete detox in an ambulatory treatment setting (if such a setting is available in the member s treatment area); and Member is not in a methadone maintenance program. 5. For stimulants: All of the criteria #1 9 must be met; For Pregnancy Enhanced Detox, criteria # 10 and 11 must also be met: 1. Member continues to meet admission criteria; 2. Another less restrictive LOC would not be adequate to provide needed containment and administer care. 3. Member is experiencing symptoms of such intensity that if discharged, s/he would likely be readmitted; 4. Treatment is still necessary to reduce symptoms and improve functioning so member may be treated in a less restrictive LOC. 5. There is evidence of progress towards resolution of the symptoms causing a barrier to treatment continuing in a less restrictive LOC; 6. Appropriate use of medications at least once per 24 hours to modify withdrawal symptoms or irregular vital signs (T>100, BP160/100, HR >100). 7. Family/guardian/caregiver is participating in treatment as clinically indicated and appropriate. 8. There is documentation of coordination of 16 Criteria # 1, 2, or 3 are suitable; criteria # 4 and 5 are recommended, but optional: 4. Member no longer meets admission criteria and/or meets criteria for another LOC, either more or less intensive. 5. Member or parent/guardian withdraws consent for treatment, 6. For Alcohol; CIWA score is < Member s individual treatment plan and goals have been met. 8. Member s support system is in agreement with aftercare treatment plan.

17 Admission Criteria Continued Stay Criteria Discharge Criteria Intoxication symptoms require both medical and psychiatric monitoring; and Member cannot be safely stabilized in a less restrictive setting. 6. For Alcohol: CIWA score is equal to or > 10 and irregular vital signs are evident (T>100, BP160 /110, HR>=110) or member has an elevated CIWA score in the absence of elevated BP or HR and is prescribed a beta blocker or other antihypertensive medication. 7. Member has a co-morbid psychiatric disorder with impaired judgment, mood instability or lability that would predispose them to immediate relapse to substance use in the absence of further stabilization of their psychiatric condition. 8. Member is currently pregnant, and does not currently require acute medical or psychiatric hospital LOC. treatment with state or community agencies, if involved. 9. There must be evidence of attempts of discharge planning to transition to a less intensive LOC. For Pregnancy Enhanced Detox: 10. Pregnant member continues to need medically managed detox services as noted above in # Intensive psycho-education related to detox, addiction, and pregnancy is still necessary in order to safely transition member to the next LOC or to effectively return member to the community with community based services. 17

18 E. Adolescent Acute Inpatient Detoxification and Rehabilitation for Substance Use Disorders Adolescent acute inpatient detoxification (detox) and rehabilitation (rehab) for substance use disorders is a 24-hour therapeutic treatment setting that has the capacity to provide both medically monitored detox, including comprehensive assessment and diagnosis, and substance use rehab treatment, with aftercare planning and referral. The program is family-centered, using the strength-based model to introduce and engage the adolescent and family to recovery, using the 12-step model. The program also provides individualized therapeutic treatment. Treatment in this level of care (LOC) is generally within 30 days. Admission Criteria Continued Stay Criteria Discharge Criteria Criterion # 1 must be met; and any one of criteria # 2-8 must also be met: 1. Member must be an adolescent (age 13 17) with a DSM or corresponding ICD substance use disorder diagnosis at risk of acute or subacute withdrawal with mild, moderate to severe symptoms. 2. Member has a complicated addiction or co-occurring medical condition which requires 24 hour inpatient nursing services. 3. Member s co-occurring condition and continued substance use place the member at risk for damage to physical health 4. Member requires 24 hour supervision and a high intensity therapeutic milieu to address the following: Access to nursing and medical monitoring and treatment; Dangerousness and/or lethality to self or others; Environmental interference with recovery efforts; Limited social functioning; Limited ability to care for self; Severity of addiction; Relapse prevention skills. 5. Member exhibits severe impairment in life areas such as legal, family, school or work and has been unable to achieve or maintain sobriety at a less intensive LOC. 6. Member has low readiness to change and needs structured motivational interventions. 7. Member has high relapse or continued problem/use potential with cravings and inability to defer gratification. 8. Member s home environment is not conducive to recovery (e.g. due to abuse, criminal activity, drug or alcohol use). Criteria # 1-8 must be met: 1. Member continues to meet admission criteria; 2. Another less restrictive LOC would not be adequate to provide needed containment and administer care. 3. Member is experiencing symptoms of such intensity that if discharged, s/he would likely require a more intensive LOC; 4. Treatment is still necessary to reduce symptoms and improve functioning so member may be treated in a less restrictive LOC. 5. There is evidence of progress towards resolution of the symptoms causing a barrier to treatment continuing in a less restrictive LOC; 6. Family/guardian/caregiver is participating in treatment as clinically indicated and appropriate. 7. There is documentation of coordination of treatment with state or community agencies, if involved. 8. There must be evidence of attempts at discharge planning to transition to a less intensive LOC. Criteria #1, 2, 3 or 4 are suitable; criteria 5 and 6 are recommended, but optional: 1. Member no longer meets admission criteria and/or meets criteria for another LOC, either more or less intensive. 2. Member or parent/guardian withdraws consent for treatment. 3. Member does not appear to be participating in treatment plan. 4. Member is not making progress towards goals and there is no expectation of any progress. 5. Member s individual treatment plan and goals have been met. 6. Member s support system is aware and in agreement with the aftercare treatment plan. 18

19 F. Transitional Care unit (TCU) Transitional Care Units are designed for youth, under the age of 19, who: Are in the care or custody of the Department of Children and Families (DCF); Have been determined not to need residential care; Are expected to be placed at home with parent/caregiver, foster care or community-based group home; and No longer meet medical necessity criteria for continued stay at an inpatient or intensive community-based acute treatment or community based acute treatment (ICBAT/CBAT) level of care (LOC). TCU is a less restrictive setting than inpatient or ICBAT/CBAT, and more structured than partial hospitalization or outpatient treatment. TCU is solely intended to meet the needs of youth who are ready to leave an acute inpatient setting or ICBAT/CBAT; and priority is given to youth in inpatient settings. Transitional care services are designed to facilitate transition to the youth s next placement setting through comprehensive transition planning and medically necessary behavioral health services. Admission Criteria Continued Stay Criteria Discharge Criteria Criteria #1-8 must be met; and criterion #9 is sufficient for exclusion: 1. Member is under the age of Member is in the care or custody of the Department of Children and Families (DCF). 3. Member has a DSM or corresponding ICD diagnosis 4. Member has been determined not to need placement in a residential school. 5. Member does not meet continued stay criteria for acute psychiatric hospital or CBAT. 6. The expected placement settings for the member are: to return home with parents/caregivers, a foster care placement, or a community based group home. 7. Consent for TCU has been obtained from DCF. 8. Member does not have complex medical or developmental conditions that would preclude beneficial use of this service. Exclusionary Criteria: 9. The expected placement settings for the youth is a residential school setting, Intensive Residential Treatment Program (IRTP), Behavioral Intensive Residential Treatment (BIRT), or Department of Mental Health (DMH) continuing care. All of the following criteria must be met: 1. Member continues to meet admission criteria; 2. Another less restrictive LOC would not be adequate to provide needed containment and administer care. 3. Member remains without an identified or available, specific placement resource. 4. Member continues to have medically necessary therapeutic needs. Criteria #1, 2, 3, 4, or 5 are suitable; criterion #6 is recommended, but optional: 1. Member no longer meets admission criteria and/or meets criteria for another LOC, either more or less intensive. 2. An appropriate placement setting has been located and transitional services are in place. 3. The planned placement for the member has changed to residential school, or other residential setting. 4. The goals and objectives for TCU have been substantially met. 5. Member is over the age of DCF is aware and in agreement with the aftercare treatment plan. 19

20 G. Dual Diagnosis Acute Treatment (DDAT) DDAT is a 24-hour therapeutically-planned group living program, serving members with co-occurring substance use and behavioral health disorders who are motivated and have sufficient potential to respond to active treatment, who need a protected and structured environment, and for whom outpatient, partial hospitalization, or acute hospital inpatient treatments are not appropriate. DDAT level of care (LOC) also provides individualized therapeutic treatment. This program is not equivalent to acute detoxification; rather, it is designed to maintain the member in the least restrictive environment for stabilization and integration. The DDAT must be both physically and programmatically distinct if it is a part, or a sub-unit, of a larger treatment program. Consultations and psychological testing as well as routine medical and psychiatric care, are provided when appropriate and are included in the per diem rate. DDAT is generally completed in 1 14 days, provided that realistic discharge goals are set at admission, and that there is full participation in treatment by the member and his or her family members, when appropriate. Admission Criteria Continued Stay Criteria Discharge Criteria All of the following criteria must be met: 1. DSM or corresponding ICD substance use disorder diagnosis, which require, and are expected to respond to, intensive, structured treatment intervention. 2. Member agrees to voluntary admission and is able to appropriately participate in safety planning. 3. Member s psychiatric condition does not require 24-hour medical/psychiatric and nursing services. 4. Member may require medically monitored ATS detoxification (detox) services. 5. Member requires 24 hour supervision in a high intensity milieu to address the following: Access to nursing and medical monitoring; Environmental interference with recovery efforts; Severity of addiction; Need for relapse prevention skills. All of the following criteria must be met: 1. Member continues to meet admission criteria; 2. Another less restrictive LOC would not be adequate to provide needed containment and administer care. 3. Member is experiencing symptoms of such intensity that if discharged, s/he would likely be readmitted; 4. Treatment is still necessary to reduce symptoms and improve functioning so member may be treated in a less restrictive LOC. 5. There is evidence of progress towards resolution of the symptoms causing a barrier to treatment continuing in a less restrictive LOC; 6. Medication assessment has been completed, when appropriate, and medication trials have been initiated or ruled out. 7. Family/guardian is participating in treatment as clinically indicated and appropriate. 8. Coordination of care and active discharge planning are ongoing, with goal of transitioning the member to a less intensive LOC. Criteria # 1, 2, 3 or 4 are suitable; criteria # 5 and 6 are recommended, but optional: 1. Member no longer meets admission criteria and/or meets criteria for another LOC, either more or less intensive. 2. Member withdraws consent for treatment and does not meet criteria for involuntary/ mandated treatment. 3. Member does not appear to be participating in treatment plan. 4. Member is not making progress towards goals, nor is there any expectation of any progress. 5. Member s individual treatment plan and goals have been met. 6. Member s support system is in agreement with the aftercare treatment plan. 20