How To Care For A Member Of A Psychiatric Rehab Facility

Transcription

1 2015 Level of Care Guidelines SH & ESH Supported Housing and Enhanced Supported Housing Psychiatric Rehabilitation services are defined by the Bureau of TennCare per the Contractor Risk Agreement (CRA). Copies of the CRA can be found at the Tennessee Government Website. UnitedHealthcare Community Plan adheres to the definitions of Psychiatric Rehabilitation services (including supported housing) provided in the CRA, and requires providers to adhere to these definitions as well. Description of Supported Housing (SH) services: Supported housing services refers to services rendered at facilities that are staffed twenty-four (24) hours per day, seven (7) days a week with associated mental health staff supports for individuals who require treatment services and supports in a highly structured setting. These mental health services are for persons with serious and/or persistent mental illnesses (SPMI) and are intended to prepare individuals for more independent living in the community while providing an environment that allows individuals to live in community settings. Given this goal, every effort should be made to place individuals in facilities near their families and other support systems and original areas of residence. Supported housing services are mental health services and do not include the payment of room and board. Description of Enhanced Supported Housing (ESH) services: In addition to the description for SH services, members in ESH will require care exceeding support and intervention levels provided in standard Supported Housing. Behavioral health care needs may include mental health and/or substance abuse. SH Admission Criteria: ALL of the following criteria must be met: 1. The Member s care needs meet the definition of the TennCare Medical Necessity Criteria. This can be found at pdf 2. SH services must be ordered by an independently licensed behavioral health clinician (MD, MSRN, APRN, Licensed Psychologist, LCSW, LPC, LMFT, or LSPE). 3. The Member is diagnosed with a diagnosis that would qualify for a TennCare Priority Enrollee rating. 4. The Member has been educated regarding and expresses an interest and willingness to participate in SH services. 5. The Member has the means to pay room and board for the group home living, or the provider has agreed to provide room and board at no cost. Level of Care Guidelines Page 1 of 5

2 6. While the Member does not require total care with daily living skills, the Member requires a level of daily support that cannot be provided in a less restrictive level of care. 7. The Member is functioning at a cognitive level that allows him/her to make gains and benefit from rehabilitative services provided in SH venues. Members with cognitive impairment from any condition (e.g. - TBI, mental retardation, dementia, schizophrenia with prominent negative symptoms, etc.) may not be appropriate for SH services if their cognitive impairment precludes them from benefitting from rehabilitative services. 8. The Member s physical health status will not impair his/her ability to make gains and benefit from Psychiatric Rehabilitative services provided in SH services. Members who have sufficient physical health issues that qualify them via Pre-Admission Evaluation (PAE) or Pre-Admission Screening and Review (PASR) for a higher level of care such as nursing home care are not appropriate for Supported Housing. 9. The Member is either stepping down from a higher level service or at risk of a higher level service such as, but not limited to, psychiatric hospitalization, Crisis Stabilization Unit, adult mental health residential treatment facility, Enhanced Supported Housing, and/or incarceration due to his/her mental illness. SH is not solely used to provide a solution for homelessness. 10. The provider is able to identify the targeted symptoms and behaviors that will be addressed with SH, the goals for the targets, and the interventions that will be provided through SH that will assist the Member toward a less restrictive setting. ESH Admission Criteria: In addition to ALL SH Admission Criteria listed above, the following is required for ESH Admission: 11. The severity of the Member s condition(s) and needs requires a level of treatment intensity, ongoing and frequent monitoring and interventions to address mental health, physical health, and/or substance abuse conditions that significantly exceed the care available in Supported Housing. SH Continued Stay Criteria: ALL of the following criteria must be met: 1. The Member continues to meet the Admission Criteria for SH. 2. SH is the least restrictive setting to meet the Member s needs. 3. The provider is actively providing services to the Member that allows him/her to acquire the skills necessary to live in a less restrictive setting of the Member s choosing upon discharge from SH services. 4. With each request for Concurrent Review, documentation is required that demonstrates the ongoing treatment and progress as it relates to SH: A. Current SH Specific Care Plan must include: i. Evidence that the Member has participated in the development and revisions of the Care Plan; Level of Care Guidelines Page 2 of 5

3 ii. Specific targets being addressed and frequency of targeted issues; iii. Specific, realistic, concrete and measureable goals with timeframes for anticipated achievement; iv. Specific and concrete interventions identified with the frequency for each intervention being provided; v. Precise care needs that relate to the mental health, physical health, and/or substance abuse condition that warrant SH are addressed. B. SH Discharge Plan: i. Evidence that the Member has participated in the development of the Discharge Plan; ii. Specific projected date of discharge to a less restrictive setting; iii. Concrete and detailed housing transition plan; iv. Specific anticipated aftercare services (mental health, physical health, and/or substance abuse) 5. The Member is making measurable gains in developing the specific skills identified by the provider to move to the less restrictive setting. ESH Continued Stay Criteria: In addition to ALL SH Continued Stay Criteria listed above, the following is required for ESH Continued Stay: 6. The severity of the Member s condition(s) and needs continues to require a level of treatment intensity, ongoing and frequent monitoring and interventions to address mental health, physical health, and/or substance abuse conditions that significantly exceed the care available in Supported Housing. SH/ESH Discharge Criteria: 1. One or more of the Continued Stay Criteria are no longer met. 2. There is lack of measurable progress or participation by the Member and there is no clinical intervention that will likely change the lack of measurable progress or participation (SH/ESH is not intended to be a continuous support service as this is not a Recovery oriented outcome and Medicaid reimbursement is intended for rehabilitative services). 3. The symptoms and behaviors identified as warranting admission to SH/ESH services have sufficiently decreased and functioning has improved to a point that the Member can be moved to a less restrictive level of care/housing. Level of Care Guidelines Page 3 of 5

4 SH/ESH Program Service Expectations: 1. Initial case review for admission will be completed with UnitedHealthcare Community Plan UM staff using forms developed for SH/ESH services. 2. Within thirty (30) days of admission to SH/ESH service, the Member will work with SH/ESH staff to develop an SH/ESH specific Care Plan that is updated at least every six (6) months. The Care Plan includes the following: a. Specific, targeted care needs being addressed that relate to the mental health, physical health, and/or substance abuse condition that warrant SH with frequency of targeted issues; b. Specific, measureable goals and timeframes; c. Specific, concrete interventions; frequency for intervention being provided; specific time frames; d. Specific projected date of discharge to a less restrictive setting. 3. Within thirty (30) days of admission to the SH/ESH service, the Member will work with SH/ESH staff to develop a Discharge Plan that is in conformance with the principles of Recovery and/or Resiliency. The plan includes the following: a. Projected date of discharge to a less restrictive setting; b. Concrete and detailed housing transition plan to include type of placement, specific locations under consideration, and steps member will take to make the final decision (visiting the housing option, transportation to the site, meeting staff); c. Specific anticipated aftercare services (mental health, physical health, and/or substance abuse). 4. SH/ESH providers are expected to coordinate and collaborate with ALL other treating providers regarding all ongoing care/services that the Member is participating in to help ensure that the Member has support toward treatment adherence and follow-up care. 5. The Member in SH/ESH will NOT be required to leave the residence during the day/evening as a condition of admittance or continued stay. As part of the Member s treatment plan, the Member should be permitted to leave the SH/ESH site independently to engage in unsupervised community activities in order to practice daily living skills. 6. Fifteen (15) hours of weekly Mental Health and/or Psychiatric Rehabilitation is required for each member at the SH/ESH residence to address the Member s needs and build on his/her strengths. These contacts/activities shall be documented in the Member s clinical record. These fifteen (15) hours should not be billed separate from a SH/ESH claim and should be included in the per diem for any SH claim. 7. Mental Health and/or Psychosocial Rehabilitation services in addition to the fifteen (15) hours provided to each member at the SH/ESH site can be offered and billed separately from those provided within SH/ESH service. Psychiatric Rehabilitation services such as IMR or Supported Employment can also be provided in addition to the Psychiatric Rehabilitation services provided. All these Psychiatric Rehabilitation services should be provided according to the Member s treatment plan and according to the Member s choice of provider(s). 8. SH/ESH services are available twenty-four (24) hours, seven days per week. Level of Care Guidelines Page 4 of 5

5 Exceptions: 1. Any exceptions to the Supported Housing/Enhanced Supported Housing criteria or service expectations must be approved in writing by UnitedHealthcare Community Plan. Level of Care Guidelines Page 5 of 5