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 is a behavioral intervention program, provided in the context of a therapeutic milieu, which provides primarily school age children/adolescents with Serious Emotional Disturbances (SED) the intensity of treatment necessary to enable them to live in the community. The program is based on behavior management principles and includes, at a minimum, positive feedback, self-esteem building and social skills training. Additional components are determined by the needs of the participants in a particular program and may include skills training in the areas of impulse control, anger management, problem solving, and/or conflict resolution. The most important element of is the consistency and qualifications of the staff providing the service. is the most intensive outpatient program available to children and adolescents. These services involve a member for a maximum of 5 hours a day, 5 days per week with a minimum of 4 hours per week. provides an alternative to residential treatment or acute psychiatric hospitalization and/or serves as a transition from these services. INSTRUCTIONS F 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. Optum is a brand used by United Behavioral Health and its affiliates.

2 1.2. The member has a Serious Emotional Disturbance i 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 Assessment and diagnosis and/or treatment planning requires observation and interaction for a maximum of 5 hours a day, 5 days per week with a minimum of 4 hours per week. Examples include: Assessment requires frequent interaction with the member, and observation of the member with others The treatment plan must be changed frequently which requires that the provider have face-to-face interactions with the member several times a week The member requires engagement and support which requires extended interaction between the member and the program. Examples include: The member requires a coordinated transition back into the community after treatment in Inpatient or a Residential Treatment Center The member/member s family has been unable to access or utilize natural resources on their own The member/member s family requires a structured environment to practice and enhance skills. This requires face-to-face interactions several times a week that cannot be provided in a less intensive setting. Examples of skills include those that help the member: Maintain their current living situation; Return to school Services are medically necessary ii. 2

3 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 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. 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 Day Treatment have been addressed to the extent that the member no longer requires The member reaches 22 years of age The member/member s family is unwilling or unable to participate in Day Treatment The member moves outside the geographic area of the s responsibility. 4. Clinical Best Practices 4.1. Evaluation and Treatment Planning 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 3

4 Background about the member s family and community; The family s medical and behavioral health histories; The member s broader resiliency goals 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 30 calendar days of the initial evaluation. 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; includes involvement of the family or individuals acting in place of the parents as often as possible, but no less than twice per month, in order to achieve improvement that can be generalized across environments; How treatment will be coordinated with other providers as well as with agencies or programs with which the member is involved As needed, the treatment plan also includes interventions that enhance the member/family s motivation, promote informed decisions, and support the member s resiliency. Examples include psychoeducation, motivational interviewing, resiliency planning, and facilitating involvement with self-help and wraparound services 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. 4

5 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, a psychiatrist is available to consult with the program during and after normal business hours A psychiatrist sees the member at least weekly The treatment plan and level of care are reassessed 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 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 Day Treatment Discharge Planning The provider and the member/member s family develop an initial discharge plan when the member accesses 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 will reoccur; and The member/member s family agrees with the discharge plan For members remaining in s geographic area of responsibility, the provider: 5

6 References Shares the discharge plan and all pertinent information with the treatment provider(s) prior to discharge Provides the member/member s family with information about: Recommended self-help and community resources; and How the member can resume services For members moving outside the s geographic area of responsibility, the provider discusses the need for and availability of services with the member/member s family. As needed, the provider assists the member/member s family with accessing services in the member s new service area. The provider shall maintain contact with the member/member s family through the transition. 1. American Academy of Child and Adolescent Psychiatry & American Association of Community Psychiatrists. (2001). CALOCUS Instrument, Version 1.5. Child and Adolescent Care and Utilization System. Retrieved from: 2. American Academy of Child and Adolescent Psychiatry. (1997). Practice Parameter for the Assessment and Treatment of Children and Adolescents. Retrieved from: 3. American Academy of Child and Adolescent Psychiatry. (2001). Practice Parameter for the Assessment and Treatment of Children and Adolescents with Suicidal Behaviors. Retrieved from: 4. Miller, T. & Mol, J.M. Association for Ambulatory Behavioral Healthcare (AABH). (2012). Standards and Guidelines for Partial Hospital Programs, Fifth Edition. 5. State of Mississippi, Administrative Code. (2013). Title 23: Medicaid, Part 206, Mental Health Services. Retrieved from Part_206.pdf. 6. State of Mississippi, Mississippi Division of Medicaid. (2013). Mississippi Medicaid Provider Reference Guide for Part 206. Retrieved from Reference-Guide-206.pdf. 6

7 i The Mississippi Medicaid Provider Reference Guide defines Serious Emotional Disturbance as a diagnosable mental disorder found in youth that is so severe and long lasting that it seriously interferes with functioning in family, school, community or other major life activities, Public Law states that: The resulting definition of SED requires children to have a psychiatric diagnosis (excluding V codes, substance abuse, and developmental disorders occurring in the absence of another diagnosable disorder) and substantial impairment in family, school or community activities. Adding an impairment indicator was meant to distinguish between children with psychiatric disorders that significantly affected their ability to function in their environment and those having only mild impairments. ii 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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