Comprehensive Behavioral Care, Inc. Level of Care Guidelines Substance Abuse Adult

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1 Comprehensive ehavioral Care, Inc. delivery system that does not include sufficient alternatives to a particular LOC and a particular patient. Therefore, CompCare considers at least the following factors when applying criteria to a given individual: Age Comorbidities: including information obtained in consultation with the Primary Care Physician and/or the Health Plan UM team Complications Progress of treatment Psychological situation Home environment, when applicable The characteristics of the local delivery system available to a particular patient should also be considered: Availability of alternative levels of care, such as intensive outpatient programs, outpatient detoxification programs or residential treatment centers in the service area to support the patient after hospital discharge. Coverage of benefits for alternative levels of care, such as residential treatment centers where needed Ability of local providers to provide all recommended services within the estimated length of stay. When the above listed member and delivery system complications are identified the Care Management staff are directed to seek internal clinical guidance through case management peer review, discussion with the Director of Clinical Services or the physician advisor. Additionally, when the member is seeking detoxification, CompCare Care Management staff is directed to carefully consider member safety related to medical stability by questions that include, but are not limited to: Co-existing medical conditions and PCP treatment and management of medical conditions Member age Past detoxification history Type of treatment facility free standing or within a medical facility Page 2 of 14

2 SUSTANCE AUSE OUTPATIENT TREATMENT Organized outpatient treatment for adults with chemical dependency may be delivered in a wide variety of settings and by addiction treatment staff with a variety of experience and credentials. The services must follow a defined set of policies and procedures or clinical protocols and usually encompass less than six contact hours per week. Individual, group and family sessions may occur with special emphasis on group and family involvement as individually indicated. The treatment is designed to help the member achieve positive changes in his or her alcohol- or other drug-using behaviors. Areas that have a potential to undermine the goals of treatment or to impair the member s ability to cope with major life tasks without the non-medical use of alcohol or other drugs must be addressed in this treatment. These areas include major familial, attitudinal, behavioral and cognitive issues or beliefs. Treatment interventions and modalities are tailored to engage the members who are at varying levels of functional maturity. This level of care is appropriate in a variety of circumstances. It may be used as 1) a step down from a more intensive level of care, 2) the initial level of care for a member, 3) an option to engage and enhance the motivation of a resistant member who is not ready to commit to recovery and is in the early stages of change, or 4) an additional level of support for a member who has had limited success within a structured treatment program. Treatment at this level of care often requires linkages with other service providers. These may include referrals for psychiatric assessment and treatment, primary care medical assessment and treatment, psychological, and/or social service agency interventions. Admission: Outpatient Treatment Must meet medical necessity 2. Must meet ALL A The member is not demonstrating any life-threatening withdrawal symptoms that require acute inpatient detoxification. The member is not suffering medical/psychiatric complications of his/her substance abuse that would inhibit ability to actively participate in and benefit from participation in the treatment OR is receiving concurrent medical or psychiatric monitoring and is stable. C The member is able to maintain abstinence or control use and pursue recovery or motivational goals and needs limited support. D The member s family and environment can support recovery with limited assistance. E The member suffers from minimal to mild impairment in social, medical, family and/or work functioning secondary to substance abuse. Page 3 of 14

3 F Comprehensive ehavioral Care, Inc. The member demonstrates an interest in working toward the goal of rehabilitation, but needs motivating and monitoring strategies to strength readiness OR the member is in early stages of change and a more intensive level of care could lead to passive compliance, increased conflict, withdrawal from treatment or be counterproductive. Continued Stay: Outpatient Treatment 1. Must meet OTH A The member and when indicated, family have participated in the treatment plan development and discharge plan. The member is making progress, but has not yet achieved the goals in the individualized treatment plan OR, if not making progress, has the capacity to resolve his or her problems OR new problems have been identified that are appropriately managed at the present level of care. Discharge: Outpatient Treatment 1. Must meet ONE A Continued stay guidelines are no longer met. Appropriate and timely treatment is available at a less restrictive level of care. Page 4 of 14

4 Intensive Outpatient Treatment Intensive Outpatient treatment for chemical dependency is usually built around a structured program run by professional staff trained in the treatment of chemical dependency. The treatment is characterized primarily by a group approach, which has didactic and process components. Critical is the component of relapse prevention with specific adaptations for the individual. Teaching the disease concept of addiction, relapse prevention, addressing family issues with involvement of family or significant others in treatment, anger management, and social issues should be included. Treatment goals should focus on present identified behaviors and include the goal of abstinence with ongoing emphasis on attendance at community-based self-help. This level of care is the first treatment option for members with support systems or use of a sober living environment and absence of significant physical and psychiatric complications. IOP programs must meet a minimum of 3 hours per day/night for usually 3 days per week but can occur up to 7 days a week. Frequency of attendance should be continually adjusted based on severity of signs and symptoms. Admission: Intensive Outpatient Treatment Must meet medical necessity 2. & Must meet ALL A The member is not demonstrating any life-threatening withdrawal symptoms that require acute inpatient detoxification The member is not suffering medical/psychiatric complications that would inhibit ability to actively participate in and benefit from participation in the treatment. C The member is unable to maintain abstinence without a structured treatment intervention during a portion of the day. D The member s support system is supportive of recovery. If the member is without a support system the member has the ability to become involved in a self-help system. E The member suffers from significant impairment in social, medical, family and/or work functioning secondary to substance abuse. F The member demonstrates an interest in working toward the goal of rehabilitation. Page 5 of 14

5 Continued Stay: Intensive Outpatient Treatment Must meet medical necessity for continued stay 2. Must meet ALL A The member has participated in the treatment plan development and discharge plan. C The member is making progress, but has not yet achieved the goals in the individualized treatment plan OR, if not making progress, has the capacity to resolve his or her problems OR new problems have been identified that are appropriately managed at the present level of care. The member has been able to become abstinent but has been unable to address social, family, and/or work related tasks leading to structure. Discharge: Intensive Outpatient Treatment 1. Must meet ONE A Continued stay guidelines are no longer met. Appropriate and timely treatment is available at a less restrictive level of care. Page 6 of 14

6 AMULATORY DRUG AND ALCOHOL DETOXIFICATION The member should be accessed daily by a medical professional regarding vital signs, physical and behavioral symptoms. There should be 24 hour access to a physician should unexpected symptoms or worsening of symptoms occur. This level of care should be considered when the member has been medically assessed, and it is determined that the member does not require around-the-clock nursing care. Members entering this level of care should have support systems capable of accessing emergency services, available if necessary to give medication. Admission: Ambulatory Drug and Alcohol Detoxification Must meet medical necessity 2. & A or must be met (For A to apply subset 1 or 2 must be checked) A The member is at risk for a severe withdrawal syndrome evidenced by a set of 1. symptoms clearly indicating an acute withdrawal process; Evidence of Alcohol and / or sedative-hypnotic withdrawal as manifested by the following: Anxiety, agitation, auditory disturbances, clouding of sensorium, delirium, diaphoresis, diarrhea, elevated vital signs (P, temperature, pulse), headache, nausea and vomiting, seizures, tactile disturbances, tremor, visual disturbances (hallucinations). & In addition to the evidence of Alcohol, Sedative-hypnotic and/or Opiate withdrawal; the presenting signs/symptoms must cause: Clinically significant distress or impairment of social, occupational, or other important areas of functioning and Require active medical/behavioral treatment that can only be provided by daily A 2 monitoring with 24 hour access to a physician should symptoms worsen. The member is at risk for a severe withdrawal syndrome evidenced by a set of symptoms clearly indicating an acute withdrawal process; Evidence or Opiate withdrawal as manifested by the following: Abdominal cramps, agitation and anxiety, anorexia, arthralgias, diaphoresis, diarrhea, dilated pupils, elevated vital signs (P, temp, pulse), irritability insomnia, lacrimation, muscle spasms, myalgias, piloerection, rhinorrhea, tachypnea, yawning. & In addition to the evidence of Alcohol, Sedative-hypnotic and/or Opiate withdrawal; the presenting signs/symptoms must cause: Clinically significant distress or impairment of social, occupational, or other important areas of functioning and Require active medical/behavioral treatment that can only be provided by daily monitoring with 24 hour access to a physician should symptoms worsen. Page 7 of 14

7 Comprehensive ehavioral Care, Inc. The member exhibits behavioral conditions complicating the member s successful detoxification at a less restrictive level of care as evidenced by at least on of the following: 1. Major depression with severe vegetative symptoms and thought process impairment such that the member could not safely participate in a less restrictive level of care. Thought process impairment or abstract thinking impairment, to such a degree as to limit the member s ability to perform activities of daily living. Continued Stay: Ambulatory Drug and Alcohol Detoxification 1. Must meet OTH A The member continues to suffer from withdrawal symptoms that require daily medical monitoring and intervention. The treatment plan implemented for the member has not led to enough improvement in the member s condition such that the member could safely move to a less restrictive level of care and sustain improvement at that level. Discharge: Ambulatory Drug and Alcohol Detoxification 1. Must meet A Continued stay guidelines are no longer met. Page 8 of 14

8 SUSTANCE AUSE PARTIAL HOSPITALIZATION Provides a structured, coordinated, intense, comprehensive, multi-modal treatment for members who have access to a sober living environment. This approach includes teaching the disease concept of addiction, relapse prevention, family issues with involvement when appropriate, anger management and social issues teaching the member to develop structure within their own lives. Additionally, emphasis is placed on community self-help groups and relapse prevention. This level of care is not to be considered the first option for members with substance abuse issues but may be used as a safe alternative to inpatient treatment, however, should not be considered as an alternative to less restrictive treatment unless the member has a documented history of failure in Intensive Outpatient in the previous 6 months of treatment This level of care may also be appropriate for members who have lost their usual structured daily activities due to substance abuse, or due to co morbid illness and lack coping skills to compensate. For these members, this level of care would be considered a focused program of transition that would stabilize the member and link him/her to community based resources and/or outpatient services. It has been determined that without the medical monitoring and direct access intervention for medical needs, the member would be too unstable to achieve optimum outcomes for and in his/her recovery process Medical monitoring is an identified need for members in this level of care and is indicated for the presenting primary diagnosis or a complicated dual presentation. y program design, medical monitoring and intervention is provided as part of the program. Though in certain situations, this level of care can exist separate from hospital based services, as a rule it is linked to a medical treatment facility. Partial hospitalization programs are run a minimum of 6 hours per day and are available a minimum of 5 days a week. Family treatment is indicated where the member may by living with family or significant others who are impacted by a member s substance use and/or are non-supportive of recovery but who are not actively opposed or sabotaging the rehabilitation goals. Multifamily groups are considered in addition to scheduled family therapy for the individual member and his/her family. Admission: Partial Hospitalization Must meet medical necessity Page 9 of 14

9 2. Must Meet ALL A The member is not demonstrating and life-threatening withdrawal symptoms that require acute inpatient The member is not suffering medical/ psychiatric complications that would prevent participation in the treatment provided. C The member has suffered such impairment with social, family, and/or work secondary to the substance abuse leading to inability to participate in routine daily activities had do not have coping skills to compensate. D E The member is unable to maintain abstinence without structured treatment intervention during the day. The member demonstrates an interest in working toward the goal of rehabilitation. Continued Stay: Partial Hospitalization Continues to meet admission and medical necessity criteria 1. Must meet ALL A The member has participated in the development of the treatment plan and discharge plan. The member has been able to become abstinent but has been unable to address social, family, and/or work related tasks leading to structure. C The treatment plan has not led to enough improvement to enable the member to be treated at a less restrictive level of care and sustain improvement. Discharge: Partial Hospitalization 1. Must Meet ONE A Continued stay guidelines are no longer met Appropriate and timely treatment is available at a less restrictive level of care. Page 10 of 14

10 ACUTE INPATIENT DRUG - ALCOHOL DETOXIFICATION HOSPITALIZATION In-patient settings provide around-the-clock intensive, psychiatric medical and nursing care, continuous observation, and control of behavior as needed to ensure safety to members and others, as well as comprehensive multi-modal therapy for member and member support system. This level of care should not be considered until after the member has been evaluated medically. This level of care is not justified by simple intoxication or fear of relapse. Initial Inpatient (Drug & Alcohol) DETOX Authorization Must meet medical necessity 2. Must meet at least ONE: A OR OR C (For A to apply subset 1 or 2 must be checked) A The member is at risk for a severe withdrawal syndrome evidenced by a set of symptoms 1 clearly indicating an acute withdrawal process; Evidence of Alcohol and / or sedativehypnotic withdrawal as manifested by the following: Anxiety, agitation, auditory disturbances, clouding of sensorial, delirium, diaphoresis, diarrhea, elevated vital signs (P, temperature, pulse), headache, nausea and vomiting, seizures, tactile disturbances, tremor, visual disturbances (hallucinations). & In addition to the evidence of Alcohol, Sedative-hypnotic and/or Opiate withdrawal; the presenting signs/symptoms must cause: Clinically significant distress or impairment of social, occupational, or other important areas of functioning and Require active treatment that can only be provided by around the clock nursing A 2 care and medical intervention on a daily basis. The member is at risk for a severe withdrawal syndrome evidenced by a set of symptoms clearly indicating an acute withdrawal process; Evidence or Opiate withdrawal as manifested by the following: Abdominal cramps, agitation and anxiety, anorexia, arthralgias, diaphoresis, diarrhea, dilated pupils, elevated vital signs (P, temp, pulse), irritability insomnia, lacrimation, muscle spasms, myalgias, piloerection, rhimorrhea, tachypnea, yawning. & In addition to the evidence of Alcohol, Sedative-hypnotic and/or Opiate withdrawal; the presenting signs/symptoms must cause: Clinically significant distress or impairment of social, occupational, or other important areas of functioning and Require active treatment that can only be provided by around the clock nursing care and medical intervention on a daily basis. History of prior complicated and potentially life-threatening withdrawal such as seizures, delirium tremens or acute psychotic symptoms. Page 11 of 14

11 C Comprehensive ehavioral Care, Inc. The member has medical complications that, in combination with substance abuse, present a life-threatening health risk. A medical consultation is necessary to determine whether a medical admission is indicated for such a member. 3. & Must meet at least ONE A The member exhibits behavioral conditions complicating the members successful detoxification at a less restrictive level of care evidenced by: Major depression with severe vegetative symptoms and thought process impairment such that the member could not safely participate in a less restrictive level of care. The member exhibits behavioral conditions complicating the members successful detoxification at a less restrictive level of care evidenced by: Thought process impairment or abstract thinking impairment, to such a degree as to limit the member s ability to perform basic activities of daily living. Continued Stay, Inpatient Drug / Alcohol DETOX 1. Must meet ONE A The member continues to suffer from withdrawal symptoms that require active treatment efforts that can only be provided by around the clock intensive nursing care and documentation of daily physician contact with the member. The member has developed a serious adverse reaction to medication requiring around the clock medical intervention that cannot be provided at a less restrictive level of care C The member s co morbid medical or behavioral illness requires active treatment that can only be provided by around the clock nursing care and medical intervention on a daily basis 2. & Must Meet The treatment plan implemented for the member has not led to improvement in the member s condition to allow the member to safely move to a less restrictive level of the care and sustain improvement at that level. Discharge Guidelines, Inpatient Drug /Alcohol DETOX 1. Must meet ONE A Continued stay guidelines are no longer met. Appropriate and timely treatment is available at a less restrictive level of care. Page 12 of 14

12 INPATIENT SUSTANCE AUSE - REHAILITATION/ RESIDENTIAL TREATMENT Residential care is to be considered when a treatment milieu is considered necessary for a member to develop more adaptive coping mechanisms and facilitate a life style change in areas involving substance abuse that can neither be addressed at a lower level of care nor require an inpatient intervention. The facility must have the capability to provide, as needed, medical and psychiatric monitoring of underlying physical and/or psychiatric illnesses and medical assessment and monitoring of withdrawal syndromes to ensure member safety. The treatment plan should address relapse prevention with individual adaptations. Prior to admission, less restrictive levels of care should be considered and attempted. This level of care is expected to stabilize the member is preparation for transition to a less restrictive level of care with a goal of reintegration into the community and is not to be considered solely for convenience or as an alternative to incarceration. Admission: Inpatient Rehabilitation/ Residential Treatment Must meet medical necessity 2. Must meet ALL A The member is medically stable so that withdrawal symptoms, if present are not life threatening and can be safely monitored at this level of care. Member is not experiencing medical complications that prevent active participation and member is cognitively able to actively participate and benefit from treatment. The member demonstrates an interest in working toward rehabilitation C The member has been unsuccessful in achieving abstinence for 6 months or more with active participation in IOP rehabilitation in the past 12 months. OR The member has failed to follow through with IOP Rehabilitation, including partial hospitalization, after 2 or more inpatient detoxifications. 3. & Must meet ONE A The member suffers form a co-morbid psychiatric illness or has bizarre thinking or psychomotor agitation/retardation that prevents participation at a less restrictive level of care. The members living environment jeopardizes ability to achieve abstinence i.e.; family opposition to treatment or family actively involved in own substance abuse or severity dysfunctional living situation. C The member s social, family, occupational functioning is severely impaired secondary to substance abuse where much of the daily activity is focussed on obtaining, using or recuperating from substance abuse. Page 13 of 14

13 Continued Stay: Inpatient Rehabilitation/ Residential Treatment 1.Must Meet OTH A The member has participated in the development of the treatment plan including the discharge plan but continues to suffer from problems that caused the admission or additional problems have emerged. The treatment plan has not led to enough improvement to allow member to move to a less restrictive level of care and sustain improvement. Discharge: Inpatient Rehabilitation/ Residential Treatment 1. Must meet ONE A Continued stay guidelines no longer met Appropriate and timely treatment is available at a less restrictive level of care. Page 14 of 14

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