Optum By United Behavioral Health Mississippi Coordinated Access Network (CAN) Medicaid Level of Care Guidelines

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1 Optum By United Behavioral Health 2015 Mississippi Coordinated Access Network (CAN) Medicaid Level of Care Guidelines Assertive Community Treatment is a multi-disciplinary, selfcontained clinical team approach providing comprehensive mental health and rehabilitative services. Team members provide long-term intensive care in natural community settings. The team provides all mental health services rather than referring individuals to different mental health providers, programs, and other agencies. Major activities under ACT/PACT may include: member-specific treatment planning team meets daily to plan services, assesses individuals community status and share information to coordinate services; individual supports for activities of daily living, financial management, skills training, medication support; coordination with collaterals sharing information with healthcare and other providers; individual clinical interventions therapy, diagnosis and assessment. INSTRUCTIONS FOR USE Optum s Level of Care Guidelines are used to standardize coverage determinations, promote evidence-based practices, and support member s recovery, resiliency, and wellbeing. Optum s Level of Care Guidelines are derived from generally accepted standards of behavioral health practice. These standards include guidelines and consensus statements produced by professional specialty societies, as well as guidance from governmental sources such as CMS National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs). While this Level of Care Guideline does reflect Optum s understanding of current best practices in care, it does not constitute medical advice. Optum reserves the right, in its sole discretion, to modify its Level of Care Guidelines as necessary. 1. Admission Criteria 1.1. The member is eligible for benefits The member s physician recommends ACT, and attests that inpatient care would be necessary without this service. Optum is a brand used by United Behavioral Health and its affiliates.

2 1.3. The why now factors that precipitated access to this service (e.g., changes in the member s signs and symptoms, psychosocial and environmental factors, or level of functioning) indicate that the member requires assistance with accessing treatment and/or community resources. Examples include: The member primarily relies on the Emergency Room for behavioral health services Impairment of behavior or cognition interferes with Activities of Daily Living to the extent that the member requires significant support or assistance The member is not in imminent or current risk of harm to self, others, and/or property Co-occurring behavioral health or medical-surgical conditions can be safely managed The member and the member s family are willing and available to actively participate in ACT Services are medically necessary i. 2. Continued Service Criteria 2.1. The admission criteria are still met Services continue to be medically necessary The why now factor leading the member to access Assertive Community Treatment have been identified and are integrated into the treatment plan Best practices are being provided timely with sufficient intensity to address the needs of the member/member s family The member is not receiving community based mental health services from any provider other than the ACT provider The member is not receiving psychosocial rehabilitation, senior psychosocial rehabilitation, or day support simultaneously with ACT. 2

3 3. Discharge Criteria 3.1. The continued stay criteria are no longer met. Examples include: Services are no longer medically necessary The why now factors which led the member to access ACT have been addressed to the extent that the member no longer requires ACT The member/member s family is unwilling or unable to participate in Assertive Community Treatment The member moves outside the geographic area of the Assertive Community Treatment s responsibility. 4. Clinical Best Practices OR OR 4.1. Evaluation and Treatment Planning The ACT team is coordinated by a responsible provider who: Is a behavioral health provider; Has knowledge and competencies that meet the member s needs; Provides clinical supervision of the ACT team; Provides direct services to the member The provider completes an initial evaluation at the time of intake and as needed for reassessment. Information is collected from the member/member s family about the following, and is used to determine the nature of the member/family s problems, the factors contributing to the problems, and the most appropriate course of treatment: The why now factors which led to admission; The member s current signs and symptoms, strengths and weaknesses; The member s developmental history; The member s history of treatment Background about the member s family and community; The family s medical and behavioral health histories; The member s broader recovery goals. 3

4 The provider uses the findings of the evaluation to assign a DSM/ICD diagnosis The provider and, whenever possible, the member/member s family use the findings of the initial evaluation and the diagnosis to develop a treatment plan within the first 14 days of treatment. The treatment plan should address: The type, amount, frequency and duration of treatment; The expected outcome for each problem to be addressed expressed in terms that are measurable, functional, time-framed and directly related to the why now factors; How the member s family and other natural resources will participate in treatment when clinically indicated; How treatment will be coordinated with other providers as well as with agencies or programs with which the member is involved The treatment plan includes a crisis intervention plan As needed, the treatment plan also includes interventions that enhance the member/family s motivation, promote informed decisions, and support the member s recovery. Examples include psychoeducation, motivational interviewing, resiliency planning, and facilitating involvement with self-help and wraparound services In the event that not all information is available at the time of the evaluation, there must be enough information to guide development of the treatment plan, and support the need for Assertive Community Treatment The provider informs the member/member s family of safe and effective treatment alternatives, as well as the potential risks and benefits of the proposed treatment. The member/member s family gives informed consent acknowledging willingness and ability to participate in treatment and abide by safety precautions Treatment focuses on addressing the why now factors to the point that the member s condition can be safely, efficiently, and effectively treated in a less intensive level of care, or the member no longer requires care During admission: The member is seen 3 times per week on average. The ACT team has the capacity to 4

5 see the member more frequently. Reasons for more frequent contact include: The member s signs and symptoms have worsened The member s response to a new medication needs to be monitored The member is experiencing an acute serious life event The ACT team meets daily to assess the member s status and to plan services The program has procedures in place for availability and response 24 hours a day, 7 days a week A psychiatrist is available to consult with the program The treatment plan and level of care are reassessed at least every 30 calendar days. The treatment plan and level of care may be reassessed more frequently when the member s condition improves, worsens or does not respond to treatment When the member s condition has improved, the provider determines if the treatment plan can be altered, or if the member can be discharged When the member s condition has worsened or not responded to treatment, the provider verifies the diagnosis, alters the treatment plan, or determines that the member s condition should be treated in another level of care An updated biopsychosocial assessment is completed within 30 calendar days of admission which much address: The family system; Identify the primary caretaker(s) and supports; and Identify both the member s and primary caretaker s functional adaptability for learning and retaining cognitive, behavioral and other therapeutic techniques The ACT team provides ongoing support and liaison services for members who are hospitalized or incarcerated. 5

6 4.2. Discharge Planning The provider and the member/member s family develop an initial discharge plan when the member accesses Assertive Community Treatment The provider and the member/member s family update the initial discharge plan in response to completion of goals ensuring that: An appropriate discharge plan is in place prior to discharge; The discharge plan is designed to mitigate the risk that the why now factors which precipitated access to Intensive Outpatient Program will reoccur; and The member/member s family agrees with the discharge plan For members remaining in ACT s geographic area of responsibility, the provider: Shares the discharge plan and all pertinent information with the treatment provider(s) prior to discharge Provides a copy of the discharge plan to the member s caretaker Provides the member s caretaker with information about: Recommended self-help and community resources; and How the member can resume ACT Provides a written prescription for a 30-day supply of all medications prescribed for the member if the current supply does not exceed 30 days For members moving outside the ACT s geographic area of responsibility, the provider discusses the need for and availability of ACT with the member/member s family. As needed, the ACT provider assists the member/member s family with accessing ACT in the member s new service area. The ACT provider shall maintain contact with the member/member s family through the transition. 6

7 References 1. Allness, D, Knoedler, W. (2003). National Program Standards for ACT Teams. Retrieved from 2. Bustillo, J, Weill, E. (2014) Psychosocial interventions for severe mental illness. Retrieved from 3. Commission on Accreditation of Rehabilitation Facilities. Behavioral Health Standards Manual. Tucson, AZ; CARF International, National Association of Mental Health Planning and Advisory Councils. (2000). Evidence-Based Assertive Community Treatment. Retrieved from: 5. Phillips, S, Burns, B, Edgar, E, Muesser, K.T., Linkins, K.W., Rosenheck, R.A., et al. (2001) Moving Assertive Community Treatment Into Standard Practice, Psychiatric Services, 52 (6), State of Mississippi, Administrative Code. (2013). Title 23: Medicaid, Part 206, Mental Health Services. Retrieved from Part_206.pdf. 7. State of Mississippi, Mississippi Division of Medicaid. (2013). Mississippi Medicaid Provider Reference Guide for Part 206. Retrieved from Reference-Guide-206.pdf. 8. Substance Abuse and Mental Health Services Administration. (2008). Assertive Community Treatment (ACT) Evidence-Based Practices (EBP) KIT. Retrieved from: Community-Treatment-ACT-Evidence-Based-Practices-EBP-KIT/SMA i Mississippi Administrative Code Title 23, Part 206 defines medically necessary as health care services that a provider, exercising prudent judgment prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are: a. Appropriate and consistent with the diagnosis of the treating provider and the omission of which could adversely affect the patient s medical condition, b. Compatible with the standards of acceptable medical practice in the United States, c. Provided in a safe, appropriate and cost-effective community-based setting given the nature of the diagnosis and the severity of the symptoms, d. Not provided solely for the convenience of the beneficiary or family, or the convenience of any health care provider, e. Not primarily custodial care, f. There is no other effective and more conservative or substantially less costly treatment service and setting available, g. The service is not experimental, investigational or cosmetic in nature, and h. All Mississippi Medicaid regulations, program rules, exclusions, limitations, and service limits, etc., apply. The fact that a service is medically necessary does not, in itself, qualify the service for reimbursement. 7

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